Senior Housing and Community Support Specialist

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 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 take on ownership of one or more special project(s) within the department. As a trusted member of the community, 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 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 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. Due to these special responsibilities, the SHCS will maintain a slightly smaller caseload than a HCS.

Position: Senior Housing and Community Support Specialist

Department: Living Well At Home Program

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,