Senior Housing and Community Support Specialist, Behavioral Health/Population Health Research

• Position: Senior Housing & Community Support Specialist
• Department: Research - ELAHP
• Location: Boston, MA
• Schedule: 40 hours per week, Hybrid

Position Summary

The Senior Housing and Community Support (SHCS) Specialist will provide case management services to high-risk patients with behavioral health diagnoses who are experiencing long-term homelessness, as well as ownership of one or more special project(s) within the department. The SHCS Specialist will help patients access and obtain and stabilizing in independent housing. SHCS 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/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. The SHCS provides community-based one-on-one support in collaboration with family, social supports, and their health care team, both pre- and post-tenancy.

In addition to working directly with clients, the SHCS will take ownership of at least one special project within the department, and will provide coaching and mentoring to a selected number of HCS. The special project(s) will be determined by both SHCS interests, and pressing needs within the department, and may include improvement or development of partnerships, internal processes, fostering of new partnerships and resources that clients can access, or other projects as needed.

Job Responsibilities

• 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.

Special Projects

Spearheads at least one special initiative within the department, taking primary responsibility for development and implementation of this project, with supervision from LWAH leadership team

• Demonstrates ability to professionally represent BMC with external organizations
• Develops a project plan and coordinates others to implement plan on a timeline
• Demonstrates ownership and ability to work autonomously to complete the special project

Mentorship and Coaching

Supports the professional development of a selected number of Housing and Community Support Specialists, including providing training, periodic coaching sessions, and modeling excellent professional work and behavior

Provides peer mentorship in the onboarding phase for new staff, including orienting new staff to best practices, demonstrating high-quality case work, answering questions that arise from new staff, and communicating closely with the supervisor of new hires on progress

(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

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, Skills & Abilities

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

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.

Job Benefits

• Competitive pay
• Tuition reimbursement and tuition remission programs
• Highly subsidized medical, dental, and vision insurance options

Career Advancement/Professional Development: Access a wealth of ongoing training and development opportunities that will not only enhance your skills but also expand your knowledge base.

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