Bilingual Substance Use Navigator

Boston Health Care for the Homeless Program•Boston, MA

2d•Hybrid

About The Position

Who We Are: Since 1985, BHCHP’s mission has been to ensure unconditionally equitable and dignified access to the highest quality health care for all individuals and families experiencing homelessness in greater Boston. Over 10,000 homeless individuals are cared for by Boston Health Care for the Homeless Program each year. We are committed to ensuring that every one of these individuals has access to comprehensive health care, from preventative dental care to cancer treatment. Our clinicians, case managers, and behavioral health professionals work in more than 30 locations to serve some of our community’s most vulnerable—and most resilient—citizens. From our earliest days as a program, we have always sought to do work that is transformational: recognizing our shared humanity; centering dignity, compassion, mutual respect and supporting the right of every individual to access the highest levels of health care and every staff member to reach their fullest potential. We continue to be committed to building bridges and breaking down barriers, including systemic racism which harms us all. We provide community-based health care services that are compassionate, dignified, and culturally appropriate, incorporating social determinants of health, with the goal of breaking down the physical and systemic barriers that our patients face. Job Summary: Hours: Full time; 40 hours per week, Monday- Friday, 8:30am-5:00pm Union: Yes Union Name: 1199SEIU Patient Facing: No The Substance Use Navigator will be an integral part of a multidisciplinary team within our RISE (Reentry Initiatives for Support and Empowerment) program and will work closely with individuals experiencing housing instability who are currently incarcerated or have previously been incarcerated. BHCHP and the RISE team connect people to substance use services through multiple pathways, and the navigator will mirror this approach by working closely with BHCHP’s OBAT (Office Based Addiction Treatment) program and SPOT (Supportive Place for Observation and Treatment) program, as well as other resources within BHCHP and throughout the community. BHCHP’s RISE team aims to engage incarcerated individuals prior to release, to connect with external Medication for Opioid Use Disorder (MOUD) partners to improve transitions of care for these individuals upon release, and to improve outcomes related to drug use in this population who are at a particularly high-risk of fatal overdose upon release. BHCHP’s OBAT program offers a robust set of services for patients with opioid use disorder (OUD), with a particular focus on providing no-threshold access to buprenorphine. The OBAT program provides individualized MOUD treatment based on patients’ prior experiences and needs, rather than a one-size-fits all approach to care, including buprenorphine initiation and ongoing management. BHCHP’s Supportive Place for Observation and Treatment (SPOT) is a unique drop-in program for monitoring people who have used drugs and are at imminent risk of overdose, presenting with severe sedation. Staff build relationships with patients who mistrust the medical system, offer education about overdose prevention, and connect people to other services, including urgent care, primary care, and substance use disorder treatment. SPOT serves as a simple way for people who have used substances to prevent fatal overdose, as well as a pathway to a myriad of other health care services. The navigator will join an interdisciplinary team of doctors, nurses, a clinic/project director, therapists, care coordinators, and others working together to support individuals with a diagnosis of substance use disorder and those at high risk of fatal overdose prior to release, on the day of release, and in the post-release period to provide the following: Pre-release support includes Critical Time Intervention, case management, behavioral health services, psychiatry, recovery support groups, legal case management, MOUD evaluations, HIV and HCV screening and referrals, and referrals for recovery coaching. Services are provided directly in in-person at the jail when permitted, or by telehealth encounters. Support on day of release from jail or from court including in person visits to the jail or courthouse, transportation support, care coordination, accompanying individuals to medical appointments and to obtain prescriptions, naloxone provision and naloxone training for overdose reversal. Post-release support includes a continuation of pre-release support, as well as support with direct MOUD provision, psychiatric treatment/medication bridging, individual therapy, and Hepatitis C (HCV) treatment. BHCHP utilizes a community-based overdose prevention model to recovery, and the Navigator will be working with individuals at all stages of recovery, including individuals who are actively using drugs, with the recognition that our patients and clients get to define what recovery means to them. This position offers a tremendous opportunity to work at the intersections of the opioid epidemic, incarceration, and homelessness, to address the root causes of illness in a collaborative team-based community health center context. Applicants must be proficient in both English and Spanish. This position is funded until the end of August 2028 with the possibility for renewal. If this funding is not renewed, this position will end August 31, 2028.

Requirements

Bilingual in English and Spanish required.
Knowledge of healthy and appropriate boundaries when working with vulnerable populations; demonstrates interest and experience in working with vulnerable populations, including those with active substance use disorder, histories of incarceration, and/or homelessness.
An understanding of the criminal justice system and how it is rooted in racism and oppression; knowledge and understanding of strategies for opioid overdose prevention and response, or willingness to be trained to become expert in these topics; comfort with multiple pathways to recovery from SUD and willingness to embrace a patient-centered approach that recognizes an individual’s preferences and autonomy.
Comfortable working in medical, criminal justice, and social service settings; strong advocacy skills along with knowledge of community-based services, resources, and local recovery community; excels at problem solving and multi-tasking and is organized, efficient and goal directed.
An aptitude for thinking creatively in the engagement and support of individuals as they navigate through the challenges of substance use and recovery; strong advocacy skills along with knowledge of community-based services, resources, and local recovery community.
Computer proficiency, effective use of the Internet and Microsoft Office programs such as Word and Outlook, Microsoft Excel, PowerPoint, and familiarity with RedCap.
Ability to: work independently as well as part of a multidisciplinary team, handle confidential information, provide and receive accurate feedback without judgment or discomfort; flexibility to adapt to unforeseen needs or circumstances.
Commitment to equitable and culturally appropriate care for a wide range of diverse populations, including (but not limited to) communities of color, LGBTQ communities, non-English speaking populations, people with histories of incarceration, people with substance use disorders and behavioral health challenges, and people experiencing homelessness.

Responsibilities

Meet with patients in jails to assess patients’ financial, housing, legal, addiction treatment, and other social service needs in the pre-release period; develop comprehensive patient-centered care coordination plans to address these needs and provide support and follow up in the post-release period.
Work with program participants to ensure they are effectively bridged to community-based OUD treatment post-release; provide Navigation support in the reentry period, identify community resources, and connect participants to medical and social services such as transportation, primary care, naloxone, and housing-related resources.
Screen individuals for interest in HCV treatment and actively support their connection to BHCHP’s HCV treatment team (or other HCV treatment programs in the community).
Ensure program participants have scheduled appointments, if clinically indicated, with the following providers upon release: primary care, behavioral health including psychiatry, specialty care including HCV services, and support attendance at these appointments by facilitating transportation and/or accompanying participants.
All services should be in an accessible community – including cultural fit, language accessibility, and transportation.
Communicate regularly with RISE team members regarding the status and needs of patients releasing from SCSD using a variety of HIPAA compliant communication mechanisms including email, Tiger Text, phone, and BHCHP’s electronic medical record (EMR); serve as a liaison between the recovery community, the addiction treatment system, the medical treatment system, and the patient’s community, family and social contexts to facilitate connections across systems of care.
Systematically review the RISE team panel of patients each week, focusing on new patients and patients who are having difficulties, and upcoming releases; co-facilitate groups focused on care coordination, overdose prevention, and recovery-related topics for individuals while they are pre – and post -incarcerated.
Clearly and effectively facilitate communication between the patient, physician, therapist, psychiatrist, and any external providers maintaining appropriate confidentiality procedures and professional boundaries; document encounters in BHCHP’s Electronic Medical Record (EMR).
Participate in required onboarding activities and OD2A (Overdose to Awareness) training, including a monthly learning community with other community health centers to share opportunities and best practices, engage in shared problem-solving, and listen to guest speakers and trainings.