Community Wellness Advocate

Boston Medical Center; Boston (MA); On-site; USD 31,000 - 44,000; Full time

Benefits offered by this job

Medical

Dental

Vision

Pharmacy

Discretionary bonuses

403(b) / 403(b) matches

Flexible Spending Accounts

Paid time off

Career advancement opportunities

Well-being resources

Job summary

Boston Medical Center’s Enhanced Care Program for Seniors is seeking a Community Wellness Advocate to conduct in‑home and community visits, assess needs, and connect high‑risk patients with social services and healthcare resources.

The role requires a high school diploma or Bachelor’s degree, plus a valid driver’s license and CCHW certification. At least 2 years in healthcare or public health is preferred; bilingual skills in Haitian Creole or Spanish are a plus.

Qualifications

• HS Diploma with community experiences or Bachelor’s degree.
• Driver’s license required and CCHW certification.
• Minimum of 2 years healthcare, public health, or community-based experience.
• Fluency in Haitian Creole or Spanish preferable.

Responsibilities

• Initiates face to face contact with eligible patients to describe role and benefits.
• Schedules and completes initial visit screening, care plan, and follow ups.
• Teaches key educational messages using culturally appropriate strategies.
• Documents activities in the patient’s record and care management system.
• Provides advocacy and connects patients to social resources and services.

Skills

Interpersonal skills

English communication

Cultural sensitivity

Organizational skills

Public health interest

Spanish

Haitian Creole

Education

HS Diploma or Bachelor's degree

Job description

POSITION SUMMARY:

THE Enhanced Care Program for Seniors (ECAP) is a collaborative, interdisciplinary wrap around clinical program which provides medical and social support to complex, and vulnerable elderly patients followed within the Boston Medical Center Health System. Through home visits in the community the ECAP supports patients in managing their complex medical and social issues, empowering them to address social determinants of health which present barriers to maximizing their health status and engaging in their healthcare. The interdisciplinary team, composed of a geriatrician, nurse practitioners, community health workers, pharmacy liaison and administrative support, work collaboratively to identify and address patients’ needs and care gaps to empower and activate patients and families to engage in their healthcare. A Community Wellness Advocate (CWA) is a trusted member of the community who helps high risk patients maintain stable health and wellness along a continuum, through integrating and connecting hospital, home-based, and community-based services. CWAs are responsible for providing advocacy and case management services; developing an interdisciplinary care plan based on identified patient needs; facilitating access to social service resources and other internal and external resources; monitoring the patient’s progress; and problem-solving with patients to both accelerate and enhance access to concrete supports. CWAs provide in-home or community-based one-on-one, family, and/or interdisciplinary group support to high risk care patients and collaborates with the Patient Care Manager, PCP, and other members of the care team to conduct needs assessments to identify and respond to barriers to the patient’s health and wellness. Position: Community Wellness Advocate Department: Pop Health - Value Based Core Schedule: Full Time Required Certification: (CCHW) Community health worker

ESSENTIAL DUTIES / RESPONSIBILITIES:

• Initiates face to face contact with eligible patients to describe role, explain participation benefits and begin screening process.
• Schedules and completes initial hospital, clinic, or community-based (homes, shelters, housing agencies, substance use treatment programs, etc.) visit screening, care plan, and follow up visits and phone calls for enrolled patients within specified timeframes.
• Teaches key educational messages using a variety of culturally, linguistically and educationally appropriate strategies, in a variety of settings.
• Clearly documents all activities in the patient’s record and care management system.
• Participates with other staff in activities that include community outreach, presentations to community organizations, development of materials, and phone calls.
• Works with patients and providers to set goals for patient’s care and provides guidance for patient to achieve those goals.
• Reinforces educational messages regarding disease self-management by linking clients with supportive community services and programs.
• Presents patients at case review meetings succinctly and logically.
• Consults with Patient Care Manager, primary clinical staff, behavioral health teams and / or PCP regarding complex patient situations, demonstrating an understanding of how to solicit and incorporate provider feedback in order to continuously develop the most optimal plan for care.
• Demonstrates the ability to function within an inter-disciplinary team (nurse care coordinators, social workers, behavioral health clinicians, physicians, resource specialists, clinical support staff, etc.), connecting the patient with resources as needed.
• Records and monitors the participants’ progress toward goals within specific timeframes.
• Documents assessments and key patient updates in Epic system; documents relevant day-to-day activities and patient data.
• Prepares reports and documents as needed or requested.
• Assists patients with organizing their records, making follow-up appointments, attending follow-up appointments, and filling their prescriptions.
• Helps patients fill out applications, for example for Medical Assistance, Housing, and SNAP (Supplemental Nutrition Assistance Program).
• Provides advocacy, patient education and successful warm hand offs in accessing community-based and hospital-based programs.
• Assists patient in addressing and overcoming barriers with a range of concrete supports, including but not limited to: healthcare support services, behavioral health, financial assistance, child-care and caregiver support, housing, support with utility bills, food, financial entitlements, clothing, transportation, food pantries, violence prevention, social isolation and any other appropriate community resources.
• Coordinates with community-based long-term services and supports.
• Provide intensive home and community-based outreach, motivational interviewing and goal setting, resource connection and accompaniment to medical appointments as needed to help patients appropriately utilize healthcare.
• CWAs may visit patients in hospital and ER settings to facilitate with transitions of care.
• Establishes culturally appropriate and trusting relationships with patients and their families.
• Participates in all training activities as designated by Community Wellness Manager (CWM) and the Nurse Practitioner.
• Attends regularly scheduled supervision and other program assigned meetings.
• Develops and maintains strong relationships with the community and community resources to ensure patient access.

NOTE: The CWA will not provide hands on care or other services noted as home health services, including but not limited to: performance assessments, provision of care, treatment, or counseling; and/or monitoring of patient’s health status.

JOB REQUIREMENTS EDUCATION:

HS Diploma with community experiences or Bachelor’s degree

CERTIFICATIONS, LICENSURES, & REGISTRATIONS:

Driver’s license required (CCHW) Community health worker certification required

EXPERIENCE:

Minimum of 2 years prior healthcare, public health, or community-based experience in community setting.

KNOWLEDGE AND SKILLS:

• Basic knowledge of healthcare system.
• Outstanding interpersonal skills of foremost importance to interact with families and patients.
• Interest in community health and outreach.
• Exceptional organizational skills; ability to multi-task and work independently and as part of a team.
• Demonstrated oral and written English communication skills.
• Fluency in Haitian Creole or Spanish preferable.
• Understanding of how language, culture and socioeconomic circumstances affect health.
• Desire to work with diverse, multi-cultural and multi-lingual populations.
• Proficiency with Microsoft Office applications (i.e. MS Word, Excel, Access, Outlook) and web browsers.
• Proficiency with data entry and data tracking.

Compensation Range:

$22.84- $31.97 This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensures as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, BMCHS offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), discretionary annual bonuses and merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family well-being.

• medical
• dental
• vision
• pharmacy
• discretionary annual bonuses and merit increases
• Flexible Spending Accounts
• 403(b) savings matches
• paid time off
• career advancement opportunities
• resources to support employee and family well-being

Equal Opportunity Employer/Disabled/Veterans:

Working at Boston Medical Center is more than a job. Its a chance to make a difference as part of our mission to provide exceptional and equitable care to all. As a nationally-recognized leader in health equity, nursing, initiatives to combat climate change, and many other areas, BMC is dedicated to improving the health of our community in Boston and beyond. BMC's mission to provide exceptional care without exception extends to our employees, and we have been recognized as a top employer and best place to work. A strong sense of teamwork and support for our staff are the bedrock of BMC, as we know that we can only provide exceptional care to patients when our staff are cared for too. Boston Medical Center is an equal employment/affirmative action employer. We ensure equal employment opportunities for all, without regard to race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and or expression or any other non-job-related characteristic.

If you need accommodation for any part of the application process because of a medical condition or disability, please send an email to [e-mail] or call 617-638-8582 to let us know the nature of your request. Boston Medical Center participates in the Electronic Employment Verification Program. As an E-Verify employer, prospective employees of BMC must complete a background check before beginning their employment at the hospital. BMC requires all staff to be vaccinated against COVID-19 and flu, as well as receive a booster dose of the COVID-19 vaccine.