Health Home Housing Coordinator

University of Rochester•Brighton, NY

9d•$24 - $30•Onsite

About The Position

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive. This role strengthens comprehensive care management services by promoting housing stability, improving health outcomes, and supporting sustained engagement in medical and behavioral health treatment. Under general direction and with considerable independence, performs housing-focused care management services consistent with all URMC and NYS regulations and policies for the provision of Health Home services. Collaborates with Health Home Care Managers, patients, and community providers to address homelessness and housing instability. Establishes and maintains cooperative working relationships with housing agencies, landlords, shelters, and community providers to obtain needed housing resources and supports. Conducts housing-related assessments, as appropriate, for enrollees identifying service needs that contribute to development of the patient-centered care plan. Develops and advances individualized housing plans using person-centered practices. Reviews and discusses housing goals with patient and care team, focusing on linking individuals permanent and supportive housing, rental assistance, and community-based services within system and community providers. Provides billable Health Home care coordination services with a focus on addressing housing stability and related social determinants of health. Coordinates care with medical, behavioral health, and community-based providers to facilitate access to supportive housing resources, social services, and health promotion activities. Assists patients during transitions of care and supports engagement in ongoing treatment and rehabilitation services. Maintains accurate and timely documentation of services, patient progress, and care coordination activities within the electronic medical record in compliance with hospital policies and Health Home regulations. Participates in program quality improvement and documentation review initiatives as assigned. Maintains a reduced caseload of newly housed Health Home members to provide intensive housing stabilization and tenancy support services. Monitors housing status and evaluates factors that may impact an individual’s ability to maintain stable housing. Works collaboratively with patients to identify barriers to tenancy and develop strategies that promote independent living skills, housing retention, and community integration. Coordinates with landlords, housing providers, and community agencies to address issues that may jeopardize tenancy and to reduce the risk of eviction or housing disruption. Provides ongoing support and follow-up to reinforce housing stability and continued engagement in medical, behavioral health, and rehabilitation services. Coordinates outreach and engagement activities with acute hospital service providers including inpatient psychiatry, emergency departments, and medical units to identify patients experiencing homelessness or housing instability who may benefit from Health Home Care Management services. Collaborates with hospital staff and interdisciplinary care teams to assess patient needs and facilitate referrals to appropriate care management, rehabilitation, and community support services. Assists with care transitions by promoting early identification of housing-related needs and supporting linkage to housing stabilization resources and community-based supports following discharge. Serves as a housing and community resource subject matter expert for the Health Home care management team. Provides consultation, education, and technical guidance to care managers and interdisciplinary providers regarding housing systems, eligibility requirements, housing stabilization strategies, and community resources. Supports care transitions by assisting team members in identifying housing-related barriers and coordinating appropriate interventions and referrals. Contributes to program initiatives and population health efforts aimed at improving housing stability and supporting successful community integration for individuals with complex medical and behavioral health needs. Other duties as assigned.

Requirements

Bachelor’s Degree in an appropriate human services field required.
Two years of experience providing direct services to people with serious mental illness, intellectual/developmental disabilities, alcoholism/substance abuse, homelessness, housing instability, or experience effectively linking people with services that address social determinants of health; or an equivalent combination of education and experience required.
Must possess and maintain a valid New York State driver’s license, have a satisfactory driving record and have access to an automobile required.
Must pass NYS DOH Health Home and URMC background check requirements required.
Knowledge of Health Home Care Management services and social determinants of health required.
Knowledge of local, state, and federal housing systems, including supportive housing, rental assistance, and community-based housing resources required.
Ability to assess housing needs and contribute to development of patient-centered care plans required.
Ability to provide Health Home core services related to housing stability and complete documentation in compliance with hospital policies and Health Home regulations required.
Ability to establish and maintain cooperative working relationships with patients, hospital providers, landlords, and community agencies required.

Responsibilities

Provides housing-focused care coordination support to patients enrolled in the Strong Behavioral Health – Health Home Care Management program (Department of Psychiatry).
Collaborates directly with Health Home Care Managers, behavioral health providers, and community partners to address homelessness and housing instability as critical social determinants of health.
Responsible for assessing housing needs, developing and advancing housing plans, and facilitating access to supportive housing and community-based resources to help members find and maintain permanent housing long term.
Conducts housing-related assessments, as appropriate, for enrollees identifying service needs that contribute to development of the patient-centered care plan.
Develops and advances individualized housing plans using person-centered practices.
Reviews and discusses housing goals with patient and care team, focusing on linking individuals permanent and supportive housing, rental assistance, and community-based services within system and community providers.
Provides billable Health Home care coordination services with a focus on addressing housing stability and related social determinants of health.
Coordinates care with medical, behavioral health, and community-based providers to facilitate access to supportive housing resources, social services, and health promotion activities.
Assists patients during transitions of care and supports engagement in ongoing treatment and rehabilitation services.
Maintains accurate and timely documentation of services, patient progress, and care coordination activities within the electronic medical record in compliance with hospital policies and Health Home regulations.
Participates in program quality improvement and documentation review initiatives as assigned.
Maintains a reduced caseload of newly housed Health Home members to provide intensive housing stabilization and tenancy support services.
Monitors housing status and evaluates factors that may impact an individual’s ability to maintain stable housing.
Works collaboratively with patients to identify barriers to tenancy and develop strategies that promote independent living skills, housing retention, and community integration.
Coordinates with landlords, housing providers, and community agencies to address issues that may jeopardize tenancy and to reduce the risk of eviction or housing disruption.
Provides ongoing support and follow-up to reinforce housing stability and continued engagement in medical, behavioral health, and rehabilitation services.
Coordinates outreach and engagement activities with acute hospital service providers including inpatient psychiatry, emergency departments, and medical units to identify patients experiencing homelessness or housing instability who may benefit from Health Home Care Management services.
Collaborates with hospital staff and interdisciplinary care teams to assess patient needs and facilitate referrals to appropriate care management, rehabilitation, and community support services.
Assists with care transitions by promoting early identification of housing-related needs and supporting linkage to housing stabilization resources and community-based supports following discharge.
Serves as a housing and community resource subject matter expert for the Health Home care management team.
Provides consultation, education, and technical guidance to care managers and interdisciplinary providers regarding housing systems, eligibility requirements, housing stabilization strategies, and community resources.
Supports care transitions by assisting team members in identifying housing-related barriers and coordinating appropriate interventions and referrals.
Contributes to program initiatives and population health efforts aimed at improving housing stability and supporting successful community integration for individuals with complex medical and behavioral health needs.