Community Health Worker II - Primary Care Complex Care Mgmt in Cambridge, Massachusetts at Cambridge Health Alliance

The Complex Care Team is responsible and accountable for developing, coordinating, and facilitating care management plans and services for CHA patients who are most at risk for health deterioration, poor outcomes, and high cost/low value interventions. Our team of nurses, social workers and community health workers works in collaboration with our primary care and specialty practices to ensure that that care for the most vulnerable patients is coordinated and managed to deliver on the three goals of the Triple Aim - improved health outcomes, excellent patient experience of care and greater healthcare value. The team works to insure that high risk patients receive optimal care including acute illness management, chronic disease management, intensive care coordination and preventive care across multiple health settings and multiple physicians/providers.

Summary
The (Hospital to Home) CHW II will work closely with the Complex Care Management team, primary care and inpatient teams, and community partners providing short-term support to patients transitioning from the hospital, skilled nursing facilities (SNFs), and other post-acute care settings back to the community. The CHW will assess patient’s ability to follow discharge plan, including meds; Identify and address barriers to discharge plan, conduct a health-related social needs assessment, Insure patient has and attends CHA follow-up appointment and Identify patients with higher risk needs and refer to the Complex Care Management (CCM). All responsibilities of the CHW will be consistent with the scopes of practice acts governing community health workers in Massachusetts.

Responsibilities

Other Information