Pediatric Social Determinants of Health Community Health Worker

Massachusetts General Hospital
United States, Massachusetts, Boston
32 Fruit Street (Show on map)
Apr 14, 2025
Summary Responsible for providing advanced health education, outreach, and care coordination services to individuals and families in the community. Areas could include exercise, mental health, medication management, nutrition, health care system navigation, substance use and other health behaviors. They work closely with healthcare providers to ensure that patients receive appropriate care and support services to improve health outcomes. Does this position require Patient Care? Yes Essential Functions -Conduct in-depth assessments of patient needs, goals, and barriers to achieving good health outcomes -Provide advanced health education and coaching to individuals and families to promote healthy behaviors and self-management of chronic conditions -Collaborate with healthcare providers to develop and implement care plans for patients with complex health needs -Assist patients in navigating the healthcare system and accessing appropriate services, including health insurance and social services -Provide ongoing follow-up and support to patients to ensure continuity of care and successful achievement of health goals -Develop and implement health promotion programs and activities to address community health needs -Collect data and maintain accurate records of patient interactions and outcomes -Attend meetings and trainings related to community health promotion and education Research indicates housing, food, financial, and other forms of socioeconomic insecurity impact health outcomes. To improve our patients' health and wellbeing, MGH primary care patients are asked to complete a social determinants of health (SDH) survey annually. The goal is to identify and address SDH early by assessing and referring patients to internal and external resources. This role will work with families of pediatric patients who have screened positive for SDH needs. This role will work closely with the Medicaid ACO Community Resource Navigator (CRN) role group, with the Integrated Care Management (iCMP) Community Resource Specialist (CRS) group, and the Pediatric Department The Medicaid ACO and iCMP resource navigation teams have recently merged to build on best practices to advance health equity, improve health outcomes, and promote well-being of our MGH Primary care patients by addressing health-related social needs, system navigation, and care coordination as standard of care. The role collaborates to enhance the delivery of patient care services along the continuum of care bridging communication about patient social needs and resources available to them back to the clinical team. This position involves problem solving to ensure each unique patient is evaluated for their unique abilities and capacity in addition to their identified SDH needs. Principal Duties and Responsibilities: Assess patients/families who have screened positive on one or more of the SDH questions Determine the scope of the patient/family's need and family's ability to follow through and take action on appropriate resources Identify previous or current efforts to address the need Identify previous or current engagement with internal and/or external resources Provide patient education and referral to resources Identify and provide information on the network of services and eligibility including service provider addresses, telephone number and, as available, contact person; may involve investigation and outreach to internal and community providers Follow up with patients to confirm engagement and respond to outstanding questions or re-refer as appropriate. Assess if there are other care coordination needs within the medical, behavioral health or social systems. Connect to primary care, formal case management, social work or other appropriate Population Health programs. Documentation Systematic and uniform documentation to record engagement with patient including education and referral to resources. Systematically communicate with the patient's care team about engagement with the patient, referrals and other appropriate patient information. Identify and document gaps in internal and external services and improve workflows and resource tools when needed. The General Hospital Corporation is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.