Job Description

POSITION SUMMARY:

Boston Medical Center’s Living Well at Home Program (LWAH) provides high-quality housing case management services to support clients in obtaining and maintaining tenancy and living healthy lives in independent housing. Boston Medical Center and its affiliated providers and Community Health Centers serve tens of thousands of patients who face housing issues or are experiencing homelessness. New initiatives across the health system have led to the expansion of LWAH services, including the formation of a new Community Support Program for Homeless Individuals.

As part of the LWAH team, the Housing and Community Support (HCS) Specialist will provide case management services to high-risk patients with behavioral health diagnoses who are experiencing long-term homelessness. As a trusted member of the community, the HCS Specialist will help patients access and obtain and stabilizing in independent housing. HCS Specialists are responsible for engaging and enrolling complex patients into services; providing advocacy and case management services; providing specialty services to support a member in becoming “housing-ready” and supporting patients in the process of identifying and obtaining housing opportunities; supporting the development of an interdisciplinary care plan based on identified patient needs; facilitating access to social service resources; monitoring the patient’s progress; and problem-solving with patients to both accelerate and enhance access to housing and community-based supports. As part of an interdisciplinary team, the HCS Specialists provides community-based one-on-one support in collaboration with family, social supports, and their health care team, both pre- and post-tenancy.

Position: Housing and Community Support Specialist        

Department: Living Well at Home

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

Patient Engagement:

• Visits and supports patients across Greater Boston through intensive in-home and community-based outreach.
• Builds rapport, trust, and positive-relationships with patients through collaborative, culturally-responsive, patient-centered approaches.
• Initiates face-to-face contact through assertive outreach with eligible patients to describe role, explain participation benefits and begin screening process.
• Works with patients and providers to set goals for patient’s housing plan and overall care and provides guidance for patient to achieve those goals utilizing skills such as motivational interviewing.
• Providing patients and their support network with education, educational materials, and training about behavioral health and substance use disorders and recovery with support from clinical care teams.

Service and Care Coordination:

• Establishes strong professional rapport with all stakeholders involved in patient case, including housing providers, property managers, care team and other service providers.  
• Regularly consults with full care team, including patient social work, care management staff, primary clinical staff, behavioral health teams and other providers regarding complex patient situations, demonstrating an understanding of how to solicit and incorporate feedback from a variety of stakeholders in order to continuously develop and refine the patient’s individualized service plan.
• Mitigate any issues with tenancy promptly by collaborating with patient, property manager, landlord, care team, other service providers, and other relevant parties.
• Assists patient in addressing and overcoming barriers with a range of concrete supports, including but not limited to: physical health, behavioral health, financial assistance, child-care and caregiver support, housing, support with utility bills, food, financial entitlements, clothing, transportation, food pantries, violence prevention, social isolation and any other appropriate community resources.
• Collaborating with crisis intervention providers, state agencies, and outpatient providers, including working with these providers to develop, revise, and utilize patient safety/crisis plans
• Assists patients with acquiring, storing, and organizing files and documentation to be “housing-ready”.
• Assists patients in obtaining housing through exhaustive housing search, submission of applications, mitigation of barriers on applications, and support of patients with housing interviews, applying a driven and relentless approach to assisting clients in obtaining housing.
• Serves as the primary connection for landlords and property management through all stages of the housing process from pre-tenancy to post-tenancy stabilization.

Performance and Team Expectations:

• Conducts and updates thorough needs assessment to capture all relevant patient information in compliance with MassHealth regulations.

• Develops comprehensive, individualized service plan with patient that is based on relevant patient needs and goals, has identified housing, clinical, and community-based interventions and services, and has clearly defined and measurable goals.
• Records and monitors the participants’ progress toward goals within specific time frames.
• Presents patients at case review meetings succinctly and logically.
• Demonstrates the ability to function and communicate professionally within an inter-disciplinary team.
• Ensures that documentation in all platforms (including BMC’s electronic medical record) is up-to-date, detailed, and accurate, complying with all data entry, data integrity, and data tracking requirements for BMC.
• Develops discharge plans with patients and other providers to ensure safe and healthy transitions from services.
• Participates with other staff in activities that include community outreach, presentations to community organizations, development of materials, and staff meetings.
• Attends regularly scheduled supervision and other program assigned meetings.
• Participates in all training activities as designated by the Living Well at Home Director, Clinical Housing Manager, or Senior Operations Manager.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job.  The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

JOB REQUIREMENTS

EDUCATION:

Bachelor’s degree in a behavioral health or related field OR Two years of relevant work experience OR Lived experience of homelessness or behavioral health conditions

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED :

Driver’s license and access to a car preferred. Will be required to complete community visits across Greater Boston region in a timely manner.

EXPERIENCE:

• Minimum of 2 years prior healthcare, public health, or social services work in community-based setting
• Prior experience working with individuals experiencing homelessness preferred
• Prior experience working with individuals impacted by mental illness, substance use disorder, and/or chronic health conditions preferred

KNOWLEDGE AND SKILLS:

• Basic knowledge of housing systems, and passion for serving individuals who are unhoused through a non-stigmatizing, patient-centered approach.
• Knowledge of community resources and healthcare systems commonly used by the patient population. Preference for individual with knowledge of Boston area resources specifically.
• Understanding of the social determinants of health impacting this patient population and importance in addressing them (housing, food insecurity, transportation, etc).
• Outstanding interpersonal skills and ability to communicate in a courteous, pleasant, and professional manner with families and patients, staff, supervisors, and others.
• Ability to identify, communicate, and problem-solve issues in patient cases to improve overall care in support of patient goals.
• Ability to work both independently and as part of multi-disciplinary team.
• Demonstrated prudent judgement and professional presence and demeanor.
• Ability to adapt to changes in care delivery at local and systems level.
• Reliability, commitment to setting and meeting goals is a must.
• Exceptional organizational skills; ability to multi-task and prioritize tasks.
• Demonstrated oral and written English communication skills.
• Fluency in Haitian Creole or Spanish preferable.
• Understanding of how language, culture and socioeconomic circumstances affect health.
• Desire to work with diverse, multi-cultural and multi-lingual populations.
• Proficiency with Microsoft Office applications (i.e. MS Word, Excel, Access, Outlook) and web browsers. Proficiency with data entry and data tracking.

SPECIAL WORKING CONDITIONS (Responsible for on-call, 24 hr. coverage, etc.):

This role requires hybrid working conditions including community based outreach and home visits as well as office based work and some ability to complete work remotely at home

Equal Opportunity Employer/Disabled/Veterans

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