The MSLLC Care Transformation Organization (CTO) will support practices with bridging the gaps between systems of care and with building processes that reliably coordinate care, focusing on timely hospital and ED discharge follow-up, as well as coordinating between primary care and specialty care, and between primary care and community-based services. This coordination involves understanding the network of services available to your patients, both within the medical neighborhood and within the community.
Primarily this position will serve as a Community Health Worker (CHW) for the MSLLC Care Transformation Organization (CTO) for the Maryland Primary Care Program (MDPCP). The CHW serves as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. The CHW will also build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.
Responsibilities & Competencies
- Work closely with the Lead Care Manager and Care Team to provide care coordination services for assigned beneficiaries. CHW will manage referrals for high-risk beneficiaries that need community health support and need to improve patient engagement.
- Will be responsible for outreach days in the community and conduct an initial needs assessment and develop an intervention plan.
- Complete home and hospital visits to assist with enrollment for CHW services and to improve participant engagement.
- Work with patients and caregivers to resolve social barriers with focus on social determinants and competing priorities that impact positive health outcomes. Provide community resources to the beneficiaries to assist with food, housing, mobility, energy assistance, childcare, and other governmental programs
- Will conduct home visits/in-person follow up with beneficiaries as needed and assist beneficiaries at social services and social security visits for SNAP, TCA, and TDAP when applying for SSI/ SSDI and insurance. Also support with applications to organizations.
- Will communicate progress updates with Lead Care Manager/Care Team.
- Will document all encounters and progress update in the provider EHR or preferred practice platform - detailing efforts, resources and communications with beneficiaries. Share beneficiary concerns with the Care team. Including, but not limited to, changes to social barriers, changes in schedule and rounds.
- Required to attend or call-in for daily and weekly rounds. Weekly rounds will include a review of all beneficiaries on CHW caseload and those in outreach (referred); and clinical mandatory trainings to improve beneficiary communication and clinical skills.
- Will maintain an active and updated inventory of community resources.
- Perform other duties as required.
- BA or BS degree preferred
- 3+ experience working with Medicaid and Medicare population as a Community Health Worker or similar role.
- Ability to drive and provide own transportation
- Must have strong team building, leadership, and mentoring skills
- Effective communicator with internal and external teams
- Identifying needs for process improvements based on work-flow, data analysis and program requirements.
- Must have high organizational, performance management, and problem-solving skills.
- Have a high emotional intelligence and exceptional communication skills.
- Must have influencing skills that foster a collaborative and continuous-improvement environment.
- Proven ability to lead, motivate, and build cross-functional teams that deliver services and solutions that surpass client expectations.
- Must be client/patient-focused.
- Contribute to high-quality deliverables and/or tasks under supervision.
- Stay updated with Community Support best practices.
CHW’s support will significantly impacts the following requirements:
- Ensure patients with ED visits receive a follow-up interaction within one week of discharge.
- Contact at least 75% of patients who are hospitalized in target hospital(s), within two business days.
- Maintain patient engagement for appropriate care.
- Systematically assess patients’ social needs using evidence-based tools.
- Conduct an inventory of resources to meet patients’ social needs.
- Convene a PFAC at least once in PY 1, and integrate recommendations into care, as appropriate.
- Establishing team based care