Complex Care Coordinator (BMC Clinic & Southampton Shelter)

Boston Health Care for the Homeless Program•Boston, MA

5d•$22 - $36•Hybrid

About The Position

Since 1985, BHCHP’s mission has been to provide or assure access to the highest quality health care for all individuals and families experiencing homelessness in greater Boston. We care for over 11,000 homeless individuals each year and ensure that every one of these individuals can receive comprehensive health care, which includes primary care, behavioral health, medical respite, dental, case management, and more. Our staff work in 30+ locations across the city 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 trust, mutual respect, hope, 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 physical and systemic barriers that our patients face and provide community-based health care services that are compassionate, dignified, and culturally appropriate. This role is designed to be better integrated with multi-disciplinary teams in BHCHP’s outpatient clinics and medical respite program to facilitate communication and collaboration on some of BHCHP’s most vulnerable patients. Complex care management requires compassionate, dignified, and culturally appropriate interactions with patients that have long been disenfranchised, incorporating social determinants of health, with the goal of breaking down the physical and systemic barriers that our patients face. This Complex Care Coordinator will provide care coordination support for high-risk primary care patients at Boston Health Care for the Homeless Program. The Complex Care Coordinator will work closely with primary care teams and clinic-based case managers. This role involves flexibility to provide patient care coordination in an assigned set of clinics (at BMC Clinic and Southampton Shelter) as well as through mobile outreach to other settings where the patient frequents, resides, or otherwise receives care. The Complex Care Coordinator will work with their supervisor to determine individualized outreach based on patient needs. The Complex Care Coordinator will take responsibility for coordinating ongoing care for a panel of 25 to 50 high-risk patients. They will also provide case management services to walk-in patients for up to 50% of their time, depending on site needs.

Requirements

A bachelor’s degree in a behavioral health field (e.g., social work, human services, psychology, sociology, or related field); or at least three years of relevant professional experience.
Able to work with multidisciplinary team maintaining a good rapport with nursing staff, medical staff, other departments, and visitors.
Strong problem solving and communication skills (written and oral).
Excellent customer service skills and the ability to communicate professionally with employees and patients, both on the phone and in person.
Efficient, organized, detail-oriented, and able to complete tasks in a time-sensitive manner.
Self-directed with the ability to work independently in multiple settings.
Flexible and adaptable to different health care delivery models.
Computer skills: proficient with Microsoft Office, including Microsoft Excel, and entering narrative and other data into electronic medical records and other internet-based products.
Willingness to travel to outreach/various sites.
Valid driver’s license and car required or strongly recommended to travel to multiple sites.

Nice To Haves

Knowledge of the network of services available to homeless persons, and experience working with homeless persons preferred.
Prior case management experience preferred.
Spanish or Haitian Creole language skills strongly preferred.

Responsibilities

Work in assigned clinics (BMC Clinic and Southampton Shelter Clinic) with a multidisciplinary team of providers, nurses, behavioral health clinicians, and case managers.
This position will include a combination of scheduled clinic sessions to see walk-in patients and outreach sessions as needed, with prior supervisor approval, to engage referred patients in the place where they frequent, receive care, and/or reside, and to accompany patients to appointments, court, etc.
Document patient encounters, as well as all outreach attempts, in the electronic health record.
Collaboratively develop, and document progress towards, patient-identified goals and a plan of care for each patient.
Coordinate services and assist patients with obtaining benefits, housing, housing tenancy supports, transportation, and other services that address their health-related social needs.
Support patients’ access to public health supplies by regularly stocking BHCHP’s public health vending machine and helping patients register for access to the machine.
Develop and maintain awareness of community resources and services available to patients.
Promote appointment adherence by assisting patients with scheduling and rescheduling missed medical and behavioral appointments, including specialty care, as needed. Support referrals to SUD treatment programs as needed.
Identify and develop cooperative working relationships with service providers for people experiencing homelessness, and coordinate housing supports using Homeless Management Information Systems (HMIS) when appropriate.
Work with patients to complete MassHealth applications and redeterminations to avoid disruptions to coverage.
Successfully complete the MassHealth Certified Application Counselor exam (CAC) within 60 days of hire and maintain active certification status.
Outreach and engagement: Make best efforts, using multiple attempts and modalities, to successfully outreach and engage newly assigned patients within 30 days of their assignment to the care management panel, or within other timeframes as determined by payor.
Needs assessment: Complete intake, comprehensive needs assessment, and care plans for primary care patients referred by Accountable Care Organizations or internal care teams for high-risk care management. Update these documents at least annually or when the patient’s condition changes as required by the ACOs.
Support during transitions of care: Provide intensive, timely care coordination to patients during transitions of care, including but not limited to participating, as appropriate, in discharge planning with inpatient health care providers.
Follow-up after hospitalization: Follow up with patients face-to-face or by telephone following an inpatient or Emergency Department discharge to coordinate clinical and supportive services.
Follow billing, documentation, and assessment guidelines as required by payors.
Use data to evaluate outcomes and adjust interventions as needed.
Participate in weekly case conference meetings to discuss mutual patients with care team members to maintain integrated care model.
Participate in ongoing training on care management principles and practices.