Behavioral Health Assistant Coordinator (Homeless Services Bureau)

The Boston Public Health Commission's Homeless Services Bureau (HSB) provides emergency shelter, job training, behavioral health support, and housing services to unhoused individuals in Boston. We serve close to 5,000 individuals every year and are one of the largest providers of emergency shelters in New England. We aim to make homelessness in Boston rare, brief, and one-time. We do that by problem-solving with new guests at the front door to try to prevent anyone from entering homelessness to begin with. For individuals who do become homeless and use our shelters, we help them quickly move out of homelessness and find a safe place to call home. Once housed, we provide in-home support to ensure someone does not return to homelessness. We use a Housing First and racial justice framework, which is built on the foundation that housing is a social determinant of health, a basic need that everyone deserves, and does not require sobriety. We believe that everyone, with the right support, can succeed in housing. We foster evidence-based approaches such as trauma-informed care, harm reduction, and motivational interviewing in the delivery of our services, and ensure services are low-threshold and accessible to our guests.

Our behavioral health team provides support to guests with health and behavioral health barriers that are preventing them from moving to and succeeding in housing. This role will be based in the community and serve as a vital link connecting homeless individuals with serious mental illness, substance use disorders, and/or complex medical illnesses with needed care including mental health, substance use, and primary care as well as services that address social determinants of health needs. This work is part of a MassHealth initiative that provides qualified MassHealth enrollees with a service benefit called Behavioral Health Community Partners. This role will work as part of an interdisciplinary BH CP team and take responsibility for coordinating the care for up to 50 enrollees. They will also work closely with other care team members and will be responsible for engaging their enrollees regularly (several times a month), mostly face to face, and making sure that the enrollee is getting connected to vital services and progressing towards the goals outlined in their Person-Centered Care Plan.

DUTIES AND RESPONSIBILITIES

• Outreaches to and builds rapport with clients to engage them in immediate service needs and moving out of the shelter and into a permanent housing placement.
• Helps identified clients navigate and stay up to date on alternative housing placements, including but not limited to domestic violence shelters, safe havens, sober homes, and nursing/rest homes.
• Provides emotional and practical support and targeted case management to help clients with acute health and behavioral health and/or substance use challenges succeed in housing efforts. Collaborates and coordinates client's care with other providers as needed.
• Assists with completing intakes and assessments on clients to determine needs and eligibility for services.
• Documents clients' bed stays at institutions such as psychiatric, substance use, correctional, and medical facilities to ensure clients' length of homelessness is accurately recorded so that clients can access all appropriate resources.
• Assists clients in accessing basic needs such as income, disability benefits, SNAP, and MassHealth.
• Assists clients in obtaining all required documents and identification for housing placements.
• Refers clients to external behavioral health services, housing services, detox, and substance use treatment programs, and health services for medical and mental health care as appropriate.
• Coordinates and delivers services with Social Workers and Housing staff, which include interdisciplinary case conferencing, following up on service delivery progress, and reinforcing key and consistent messages to clients.
• Facilitates workshops and support groups.
• Connects clients to supportive services in the community of their housing placements and provides follow-up contact with Boston area social service agencies.
• Connects clients to specialized behavioral healthcare services and resources, including those for co-occurring substance abuse.

Department-wide responsibilities

• Engages all clients using a Housing First approach, delivers services using principles of trauma-informed care and harm reduction, and promotes racial equity.
• Coordinates referrals and connects clients to key services to help them find and succeed in housing, including but not limited to external housing navigation services, benefits and income maximization, community-based resources, and stabilization services.
• Transports clients to critical appointments to find and/or maintain housing.
• Maintains up-to-date and accurate service plans, client files, and client records/documents, entering timely and accurate data into BPHC's and the City's HMIS databases.
• Actively coordinates with other departments to provide integrated services to guests.
• Participates in regular team meetings and trainings.
• Other duties as required.