Medical Respite Social Worker

Boston Health Care for the Homeless Program•Boston, MA

56d•$60,000 - $96,000

About The Position

The Medical Respite Social Worker delivers comprehensive case management and behavioral health assistance to patients at the Barbara McInnis House. This role involves completing biopsychosocial assessments within 48 hours of admission, coordinating discharge plans, and connecting patients to benefits and community resources as needed. Additionally, the clinician offers behavioral health services, including supportive counseling, individual therapy, crisis intervention, and de-escalation techniques. The position necessitates close collaboration with medical providers, nursing staff, psychiatry, and community partners to ensure safe care transitions and ongoing support beyond respite care. A trauma-informed, harm-reduction, and strengths-based approach is crucial when working with patients experiencing homelessness, chronic illness, mental health challenges, substance use disorders, and trauma histories.

Requirements

MSW/LICSW/LCSW/LMHC (must obtain licensure within 18 months [LCSW] or 42 months [LMHC]).
Minimum 2 years of experience in behavioral health, substance use treatment, or medical social work.
Strong clinical skills in assessment, counseling, crisis intervention, and behavioral de-escalation.
Knowledge of psychiatric and substance use disorders, trauma-informed care, and community resources.
Ability to navigate local shelter systems and entitlement benefits.
Excellent documentation and teamwork skills.
Experience with EHR systems.
Excellent communication, interpersonal, and organizational skills; capable of working effectively in a fast-paced team environment.

Nice To Haves

Experience with unhoused and complex adults is strongly preferred.
Prior hospital or medical setting experience providing intensive case management preferred.
Proficiency in multiple languages is preferred.

Responsibilities

Conduct biopsychosocial assessments within 48 hours of admission to identify patient needs and appropriate referrals.
Coordinate discharge planning with the medical providers, treatment program specialists, and the Complex Addiction Team (CAT).
Assist in arranging transportation for discharge.
Referring to the housing team.
Maintain accurate and accessible documentation in the medical record, ensuring discharge plans and care coordination are available to the team.
Build and sustain partnerships with community agencies to support transitions to housing, treatment programs, hospitals, nursing homes, hospice facilities, and other respite facilities.
Provide supportive counseling, individual therapy as needed, and psychoeducation to address substance use, trauma, chronic illness, grief, and domestic violence.
Offer mental health crisis intervention, behavioral de-escalation, and emotional support during respite admissions.
Collaborate with the psychiatry team and nursing to create and implement treatment plans.
Serve as a resource to staff regarding behavioral health and substance use challenges, supporting a safe and therapeutic milieu.
Participate in weekly team rounds, weekly behavioral health meetings, and interdisciplinary huddles.
Support staff in managing patient behavioral issues with empathy and professionalism.
Coordinate with unit secretaries around transportation to medical appointments.
Complete PT-1, The Ride, TAP Pass applications with patients as needed.
Contribute to a team-based model of care that reflects BHCHP's mission of equity and patient-centered practice.
Referral to VNA services in collaboration with the medical team.
Referral to DMH services.