Outreach Case Manager

Boston Health Care for the Homeless Program•Boston, MA

1d•$22 - $36•Hybrid

About The Position

The Outreach Case Manager (OCM) is part of a nationally recognized, innovative multidisciplinary HIV Primary Care Team at Boston Health Care for the Homeless Program (BHCHP). The OCM provides community-based outreach, linkage, and retention services to support patients in engaging and remaining in HIV primary care. Working alongside Outreach Nurses and an Outreach Social Worker, the OCM identifies and engages a vulnerable subset of patients who would benefit from enhanced outreach-based support. The Outreach Team helps patients overcome barriers to care, including homelessness and housing instability, substance use disorder, legal system involvement, and challenges accessing insurance and other public benefits. Using a patient-centered, strengths-based approach, the OCM works intensively with patients for up to one year to promote sustained engagement in HIV primary care at BHCHP and support their transition to greater independence in managing their care. This position has been funded by the Massachusetts Department of Public Health for more than 10 years and is currently funded through June 30, 2028, with the possibility of renewal. If funding is not renewed, the position will end on June 30, 2028.

Requirements

Associate’s, or bachelor’s degree in a related field and/ or equivalent to two years’ relevant human services experience
Experience and interest in working with people living with HIV and experiencing homelessness and housing instability
Experience conducting outreach in non-clinic-based settings
Computer proficiency
Strong organizational skills
Strong interpersonal and communication skills
Demonstrated interest in working with vulnerable populations including those with active substance use disorder and mental illness
Interest and willingness to work in multidisciplinary team setting
Commitment to equitable and culturally appropriate care for a wide range of diverse populations

Nice To Haves

Experience in behavioral de-escalation, desired
Experience with electronic health records is desired
Experience in trauma informed care, motivational interviewing, and risk reduction frameworks, desired
Bilingual English-Spanish preferred

Responsibilities

Provide intensive linkage and retention outreach services to approximately 20 of the HIV team’s most vulnerable patients living with HIV and experiencing homelessness or housing instability, with a focus on building therapeutic relationships to promote medication adherence and active engagement in health care.
Accompaniment to medical, social service, housing and legal appointments and debriefing with patients after visits and updating HIV team and collaborating agencies as needed
Active follow-up on client referrals to a wide range of support services
Field-based outreach and other activities to locate patients who may be out of care, or at high risk of disengaging from care. Outreach may be conducted with other team members including HIV nurses, providers, behavioral health providers, and case managers. Outreach sites may include streets, shelters, patient homes, AIDS service organizations, hospitals, residential treatment programs, and other locales as needed. (Outreach is always done with at least one other outreach staff member)
Co-create Individual Service Plans with clients as well as with input of the multidisciplinary HIV team, monitor implementation of plans and document updates in electronic medical record
Ensure linkage to emergency psychiatric services, when necessary, in partnership with behavioral health team
Assist with care coordination during discharge planning for patients in an inpatient setting at local hospitals
Provide advocacy for patients involved in the criminal legal system, assist patients in reconnecting to care in the post-release period
Provide motivational interviewing and risk reduction counseling for patients with substance use disorders, as well as for those engaging in other high-risk behaviors
Work with team to identify potential candidates for linkage and retention intervention; as well as to identify patients who are ready to transition from the intensive outreach to more clinic-based traditional case management services
Document all client interventions/activities and referrals in electronic medical record
Complete all reporting duties as required by grant agencies, and other reports as requested
Fulfill all mandatory reporting duties as required by MA regulating agencies
Participate in weekly multidisciplinary Patient Care Meetings and monthly HIV Team meetings as well as attend Team Huddles as appropriate
Successfully complete the MassHealth Certified Application Counselor exam (CAC) within 60 days of hire and maintain active certification status.
Provide documentation for grants, projects, etc. as directed by the Supervisor
Participate in intra-agency committees