Community Wellness Advocate
5-Month Contract
Boston MA
Pay: $25-30/hr

Qualifications: 

• High School Diploma with community experience or Bachelor’s degree.
• Driver’s license and reliable access to a vehicle.
• Minimum of 2 years of healthcare, public health, or community-based experience in a community setting.
• Proficiency with Microsoft Office (Word, Excel, Access, Outlook), web browsers, data entry, and data tracking.

Preferred Qualifications: 

• Massachusetts CHW certification preferred.
• Shared experiences with the patient population (history of homelessness, chronic illness, substance use disorder, minority group experience, etc.) preferred.
• Fluency in Haitian Creole, Spanish, Cantonese, Mandarin, or Portuguese preferred.

Job Description: 
A Community Wellness Advocate (CWA) is a trusted member of the community who helps high-risk patients maintain stable health and wellness across a continuum by integrating and connecting hospital, home-based, and community-based services. CWAs provide advocacy and case management services; develop interdisciplinary care plans based on identified patient needs; facilitate access to social service and internal/external resources; monitor patient progress; and support problem-solving to enhance access to concrete supports.

CWAs deliver in-home or community-based one-on-one, family, and/or interdisciplinary group support to high-risk care patients. They collaborate with the Patient Care Manager, PCP, and care team members to conduct needs assessments and identify and address barriers to the patient’s health and wellness.

This is a hybrid role requiring presence in the community and in settings where patients live, as well as presence at the assigned clinical site. There is also an opportunity to work from home for administrative and phone-based tasks.
 

• Initiates face-to-face contact with eligible patients to describe the role, explain participation benefits, and begin the screening process.

• Schedules and completes initial hospital, clinic, or community-based visits (homes, shelters, housing agencies, substance use treatment programs, etc.) for screenings, care plans, follow-ups, and phone calls within designated timeframes.

• Teaches key educational messages using culturally, linguistically, and educationally appropriate strategies; documents all activities in the patient record and care management system.

• Participates in community outreach activities, presentations, material development, and phone outreach.

• Works with patients and providers to establish care goals and guides patients toward achieving them.

• Reinforces educational messages for disease self-management by connecting clients with supportive community services and programs.

• Presents patients at case review meetings clearly and logically; consults with RN/SW Care Managers, clinical staff, behavioral health teams, and/or PCPs regarding complex cases and integrates provider feedback.

• Functions within an interdisciplinary team (nurses, social workers, behavioral health clinicians, physicians, resource specialists, clinical support staff, etc.), connecting patients with needed resources.

• Records and monitors participants’ progress toward goals within specified timeframes; documents assessments and patient updates in the EMR system.

• Prepares reports and documentation as required.

• Assists patients with organizing records, making and attending follow-up appointments, and filling prescriptions.

• Helps patients complete applications (e.g., Medical Assistance, Housing, SNAP).

• Provides advocacy, patient education, and warm handoffs to community-based and hospital-based programs.

• Assists patients in overcoming barriers using a range of concrete supports (health services, behavioral health, financial assistance, child-care, housing, utilities, food, entitlements, transportation, clothing, violence prevention, social isolation resources, and others).

• Provides intensive home and community-based outreach, motivational interviewing, goal setting, resource connections, and accompaniment to medical appointments as needed.

• Visits patients in hospital and ER settings to support transitions of care.

• Establishes culturally appropriate and trusting relationships with patients and families.

• Participates in all training activities designated by the Community Wellness Manager (CWM).

• Attends regularly scheduled supervision and program meetings.

• Develops and maintains strong relationships with community partners and resources to ensure patient access.

NOTE: The CWA does not provide hands-on care or services defined as home health services, including performance assessments, provision of care, treatment or counseling, or monitoring of patient health status.