Commonwealth Care Alliance's (CCA) iCMP Plus ACO inter-professional teams are responsible for providing primary care and care management to a specific panel of high risk, Medicaid ACO eligible, non CCA patients. This patient group is made up of individuals with significant medical, behavioral, and social complexities that require intensive case management. This cohort of patients belong to outside organizations that are contracted with CCA to provide this complex care.

The iCMP Plus Community Health Worker (CHW) functions within and is an integral part of an inter-professional team. This team is responsible for the care coordination and care delivery of a panel of Medicaid ACO patients. The CHW will be responsible for locating and engaging through research to identify accurate contact information for Medicaid ACO patients. This individual works to overcome language, cultural and developmental barriers and engages caregivers and/or household members, as applicable. Also, ensures that Medicaid ACO patients overcome barriers to health associated with social determinants of health. The CHW has the opportunity to use evidence, knowledge of community-based resources, trauma/recovery skills, and education to influence the clinical outcomes of iCMP Plus ACO patients by impacting acute care utilization, closing of quality gaps, and optimizing primary care, behavioral health care, and SUD services. The iCMP Plus CHW will play an integral role in support to patients that are frequent ED utilizers and are re-admitted with the goal of reducing ED and re-admissions.

Engagement by the iCMP Plus CHW can occur in two different ways.

Episodic engagement is triggered by an acute event or significant change in condition of a patient which necessitates close, short-term intervention by a CHW.

Longitudinal engagement is delivered to members who have significant SDOH needs and (through behavioral diagnosis, SUD, trauma, etc.) that require a long-term relationship with the CHW.

This position requires in person visits to members in their homes and the community across various locations in Massachusetts.

• Uses internal and external resources (such as referrals, chart review and pharmacy data) to identify accurate, successful modes of communication for initial patient engagement.
• Outreach to and engage providers in research efforts, as needed.
• Outreach directly to patients.
• Utilizes communication skills such as motivational interviewing to gain agreement from the patient to participate and be receptive to the iCMP Plus Program.
• Provides education to new patients regarding iCMP Plus and the role of the Care Partner and Care Team.
• Maintains appropriate written and oral communication on a timely basis, completing documentation within 48 hours and returning non-urgent calls within 48 hours.
• Will engage in regular assessments pertaining to Social Determinants of Health (SDOH).
• Conduct regularly scheduled visits to ensure that patient's medical, behavioral, and social needs are addressed.
• Support the health education needs of the patient in collaboration with the Care Partner, Behavioral Health Specialist and PCP.
• Works toward the promotion, prevention, and reduction of health risks.
• Identify gaps pertaining to SDOH which influence barriers to patients care and influence unmet needs.
• Coordinate with the Care Partner along with the PCP and iCMP Plus inter-professional care team to identify areas of opportunity, as well as defined resources.
• Responsible for assessing health risks, completes health risk assessment (HRA).
• Provide input to patients care team on key care management/care coordination decisions.
• Coordinate appointments for patients with multiple services including PCP, specialists for both routine and acute visits.
• Assess SDOH and provide psychosocial evaluations at member visits.
• Support efforts to decrease hospital readmissions and high emergency department use.
• Supports patients with Post Discharge follow up (Post Discharge Assessment) as needed and when requested by Care Partner.
• Coordinate and contact with other care management resources the patient may be connected.
• Support patients in re-aligning to ACO, MassHealth application and benefits.
• Participate in weekly Interprofessional Care Team meetings.
• Assist members in obtaining or stabilizing housing, finances, food, heating, educational/vocational opportunities (e.g., DTA, housing applications, furniture applications ,fuel assistance, SafeLink phone, court visits, SSI applications)
• Ensures appropriate documentation of visits and activities within EPIC system.
• Addresses issues regarding substance misuse/ abuse, if indicated.
• Uses recovery strategies such as motivational interviewing, harm reduction, positive behavioral support techniques, limit setting and strength-based approaches to support patients in attaining goals.
• Provides support and notifies Care Partner regarding changes in behavior, nutrition, exercise, substance use, medication compliance, and other issues.
• Provides 1:1 education to members regarding chronic disease self-management to prevent and manage health conditions and that encourages healthy behaviors and supports members in developing healthier habits.
• Provides consultation and support to other members of the iCMP Plus Care Team.
• Other related duties may be assigned.
• Provide clinical care to members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.
• The imp PLUS CHW will provide mentoring, coaching, and training to newly hired iCMP PLUS CHWs as delegated and under supervisor of the CHW Manager, in collaboration with the iCMP PLUS Clinical Management team.

Secondary Duties & Responsibilities:

• Actively participates in the evaluation of own performance and progress
• Participates in on-going education and training to improve skills
• Assists management with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects.
• Participates in committees and workgroups that promote clinical excellence.

Preferred Training and Certifications(s):

• CHW Certification
• Housing Specialist
• Mass Health Certified Application Counselor (CAC)
• BSAS Certified Addiction Recovery Coach (CARC)
• Health/Wellness Coach Certification