Outreach Case Manager

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 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.

About the role

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. 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. 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.

Union: 1199 SEIU | Patient Facing: Yes

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.
• Linkage and retention services specifically will include:
  • Accompaniment to medical, social service, housing, and legal appointments and debriefing with patients after visits, updating the 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 the electronic medical record.
• Ensure linkage to emergency psychiatric services, when necessary, in partnership with the 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 and 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 the team to identify potential candidates for linkage and retention intervention, as well as to identify patients who are ready to transition from intensive outreach to more clinic-based traditional case management services.
• Document all client interventions/activities and referrals in the 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.

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

Qualifications

• Demonstrated interest in working with vulnerable populations including those with active substance use disorder and mental illness.
• Interest and willingness to work in a multidisciplinary team setting.
• Commitment to equitable and culturally appropriate care for a wide range of diverse populations.

Schedule

Full-time; Monday – Friday, 8:30am – 5:00pm.

Pay

The compensation increases based on years of experience and ranges from $22.25 - $35.60 per hour.

Benefits

• Competitive time off program.
• Health, dental, and vision insurance.
• 403B retirement savings plan.
• Pre-tax MBTA pass program with 40% discount.
• Additional compensation for demonstrated bilingual proficiency.
• Benefits are prorated for part-time employees.