Commonwealth Care Alliance's Community Health Worker Program is responsible for addressing the social drivers of health and/or Social Determinants of Health of dually eligible individuals, One Care and Senior Care Option (SCO), within the context of Inter-professional teams providing care delivery, care coordination and case management to CCA's Membership.

The Community Health Worker II is a highly experienced and specialized CHW within the CHW Program. The Community Health Worker II ensures that a defined panel of dually eligible individuals overcome the drivers of health associated with complex social determinants of health (SDOH) within the context of a member centric individualized plan of care. The CHW II has the opportunity to use evidence, knowledge of community-based resources, trauma/recovery skills, and education to influence the clinical outcomes of CCA's members by impacting acute care utilization, LTSS utilization, closing of quality gaps, and optimizing primary care, behavioral health care, and SUD services. The CHW II will play an integral role in reducing high ED and Inpatient utilization and Re-Admission rate related to and triggered by unaddressed social determinants of health.

The Community Health Worker II will support CCA's current and future CHW Sub-Programs such as; Doula and Housing Programs.

The Community Health Worker II reports to the CHW Manager.

The Community Health Worker II will provide mentoring, coaching and training to newly hired and current Community Health Workers I and II as delegated and under the supervision of the CHW Manager, in collaboration with the CCA Preceptorship Team.

• As an integral part of an Interprofessional Care Team and based on the fluctuating needs of a defined panel of members, the Community Health Worker II will engage in regular assessments pertaining to Social Determinants of Health, visits at regularly scheduled intervals, and conduct urgent visits to ensure that members' Plan of Care is fully comprehensive and addresses significant medical, behavioral, and social needs. The CHW II works toward the promotion, prevention, and reduction of health risks. The Community Health Worker II will support the health education needs of the member in collaboration with the care partner and PCP.
• The Community Health Worker Level II will identify gaps pertaining to SDOH that create barriers to member's care and influence unmet needs. The CHW II will coordinate with the Telephonic Care Partner along with the PCP (Primary Care Provider), and CCA's interprofessional clinical care team to identify areas of opportunity, as well as defined resources, and will work in coordination with the team to implement the care plan.
• The Community Health Worker II will support and foster mentoring, coaching and training within the CHW Program. Under the delegation and supervision of the CHW Managers, the CHW II will participate in the onboarding process of newly hired Community Health Workers I and II by providing shadow visit opportunities, reviewing and role modeling CHW Competencies as well as the role, responsibilities and scope of practice of the CHW Role. The CHW II will participate in special projects, initiatives, development and implementation of workflows, processes and programmatic performance improvement plan as delegated by the CHW Leadership Team.
• Engagement by the Community Health Worker II can occur in two different ways.
• Episodic engagement is triggered by an acute event or significant change in condition of a member, which necessitates close, short-term intervention by a CHW II. Longitudinal engagement is delivered to members who have significant and highly complex SDOH needs that require long-term intervention, trauma informed care and therapeutic relationship by the CHW II.
• The Community Health Worker II is responsible for assessing health risks. The role also includes providing input to the member's care plan and with care teams on key care management/care coordination decisions.
• Facilitates and/or delivers preventative care to members according the guidelines deemed appropriate by CCA Clinical Leadership. Guidelines may vary based on the individual makeup of the member and is based on age, co morbidities, etc. Identifies and initiates a plan to resolve areas of opportunity to meet quality metrics.
• Assess social determinants of health and provide psychosocial evaluations at member visits
• Support efforts to decrease hospital readmissions and high emergency department use
• Support member retention and connection to MassHealth benefits
• Provides Basic Diabetes education to members
• Supports health education to members on key quality metrics
• Review a checklist of member needs, prior to each visit, to assist member with scheduling ACA and MDS visits
• Review members' quality gaps prior to every visit and collaborate with care partner to close these gaps
• Participate in weekly Interprofessional Care Team meetings
• Participate in RCA as needed
• Chronic disease management training for tobacco cessation, CVD and other health education needs a member needs
• Assist members in obtaining or stabilizing housing, finances, food, heating, educational/vocational opportunities
• Liaises with CCA Care Partner and community-based PCPs/ Specialists, as needed.
• Ensures appropriate documentation of visits and activities within CCA's central enrollee record and within the record of partners as indicated. This is accomplished through either documenting oneself in multiple systems, or utilizing internal resources that will facilitate documentation.
• 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 members in attaining stated goals.
• Provides support and notifies Care Partner regarding changes in: behavior, nutrition, exercise, substance use, medication compliance, and other issues as related to the established care plans.
• 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 CCA Care Team.
• Maintains appropriate written and oral communication on a timely basis, completing documentation within 24 hours of activity, and returning non-urgent calls within 48 hours.
• Actively participates in the evaluation of own performance and progress
• Participates in on-going education and training to improve skills
• Participates in CCA quality improvement efforts.
• Assists CCA management and leadership with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects.
• Participates in committees and workgroups that promote clinical excellence and help to advance CCAs mission and business objectives.
• Other duties as assigned
• Provide clinical care to members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.