Innovations Grant

Background

Lynn Community Health Center has received a “Healthcare Innovation Grant” from the Massachusetts Health Policy Commission (HPC) as part of an $11 million statewide project to lower costs and improve care for patients with the highest health care needs.  The health center is the lead agency in a partnership that includes Eaton Apothecary, Partners Connected Health; Massachusetts Behavioral Health Partnership, a Beacon Health Options Company; and Neighborhood Health Plan.  The goal of the project is to reduce the cost of caring for a group of health center patients with serious mental illness (SMI) who also have high rates of chronic medical conditions, such as diabetes or hypertension.  These patients typically cost the health care system 350% more than an average person. The project has adopted a model of care that focuses on intensive care coordination by a Community Health Worker (CHW). 

Purpose

The CHW will as the single point of contact for a panel of patients, coordinating care among multiple providers, assessing and addressing barriers to care, and helping the patient to become a better self advocate.  This will include coordinating with clinical pharmacy services and monitoring patient compliance using Remote Medication Monitoring (provided by Partners Connected Health). This is an exciting opportunity to work as part of an integrated Primary Care and Behavioral Health Team at LCHC’s central BH department. Full time Community Health Worker needed to provide community and health center based supports to patients with mental illness and medical problems. Primary responsibilities are to educate, advocate, coach patients as well as foster the development of independent medical and mental health care skills, support the patient in addressing any social service and concrete barriers that the patient faces when working to achieve whole health and wellness. The patient’s BH/PC provider takes the lead role in devising patient centered treatment and identifying focus areas for the CHW to work with the patient. The CHW collaborates closely with the provider, nurse care manager, team nurse manager, and other members of the interdisciplinary care team. The CHW works with the patient in clinic and community settings, as well as the patient’s home.