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

Position: Senior Housing & Community Support Specialist

Department: Behavioral Health/Population Health Research

Schedule: 40 hours per week, On-site

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. 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/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.

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.