Care Coordinator

6 days ago

Boston, Massachusetts, United States Boston Health Care for the Homeless Program Full time
Job Summary

The Boston Health Care for the Homeless Program is seeking a highly skilled Care Coordinator to join our RISE (Reentry Initiatives for Support and Empowerment) program. This program aims to engage homeless, incarcerated individuals in Suffolk County, connect them with external Medication for Opioid Use Disorder (MOUD) partners, and improve transitions of care upon release.

Responsibilities
  • Meet with patients in jails to assess their financial, housing, legal, addiction treatment, and other social service needs in the pre-release period. Develop comprehensive patient-centered care coordination plans to address these needs and provide support and follow-up in the post-release period.
  • Work with program participants to ensure they are effectively bridged to community-based OUD treatment post-release, including mitigating lapses in care associated with waiting lists and other barriers.
  • Obtain program participants' consent to communicate with community-based OUD treatment providers, in accordance with HIPAA and 42 CFR; obtain informed consent to participate in the program evaluation and assist with data collection at baseline and 6-month time points.
  • Provide care coordination to support reentry, identify community resources, and connect participants to medical and social services post-release (such as transportation, primary care, naloxone, and housing).
  • Ensure program participants have scheduled appointments, if clinically indicated, with the following providers upon release: primary care, behavioral health including psychiatry, specialty care including HCV services, and support attendance at these appointments by facilitating transportation and/or accompanying participants.
  • Document all encounters with patients in BHCHP's electronic medical record (EMR), maintain accurate and up-to-date (non-clinical) records and standardized data on all patients.
  • Communicate regularly with BHCHP RISE team members regarding the status and needs of the patients releasing from SCSD using a variety of HIPAA-compliant communication mechanisms.
  • Work closely with the Recovery Coach to serve as a liaison between the recovery community, the addiction treatment system, the medical treatment system, and the patient's community, family, and social context to facilitate connections across systems of care.
  • Co-facilitate groups focused on care coordination, overdose prevention, and recovery-related topics for individuals while they are incarcerated.
  • Clearly and effectively facilitate communication between the patient, physician, therapist, psychiatrist, recovery coach, and any external providers maintaining appropriate confidentiality procedures and professional boundaries.
  • Systematically review the RISE team panel of patients each week, focusing on new patients and patients who are having difficulties, and upcoming releases.
Qualifications
  • Knowledge of healthy and appropriate boundaries when working with vulnerable populations.
  • An understanding of the criminal justice system and how it is rooted in racism and oppression.
  • Demonstrated interest and experience in working with vulnerable populations, including those with active substance use disorder, histories of incarceration, and/or homelessness.
  • Knowledge and understanding of the harm reduction framework, including strategies for opioid overdose prevention and response, safer injection techniques, or willingness to be trained to become expert in these topics.
  • Comfort in working in medical, criminal justice, and social service settings.
  • Ability to work independently as well as part of a multidisciplinary team.
  • Bilingual in English and Spanish required.
  • Computer proficiency, effective use of the Internet and Microsoft Office programs such as Word and Outlook, Microsoft Excel, PowerPoint, and familiarity with RedCap.
  • Ability to handle confidential information.
  • Commitment to equitable and culturally appropriate care for a wide range of diverse populations.

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