Medical Respite Social Worker

Who We Are

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 are committed to ensuring that every one of these individuals has access to comprehensive health care, from preventative dental care to cancer treatment.

Our clinicians, case managers, and behavioral health professionals work in more than 30 locations to serve some of our community’s most vulnerable—and most resilient—citizens.

From our earliest days as a program, we have always sought to do work that is transformational: recognizing our shared humanity; centering dignity, compassion, mutual respect and supporting the right of every individual to access the highest levels of health care and every staff member to reach their fullest potential. We continue to be committed to building bridges and breaking down barriers, including systemic racism which harms us all.

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.

*** NOW OFFERING A $4,000 SIGN ON BONUS***

Hours: Full-time; 40 hours per week, Monday-Friday, 8:30 am – 5:00 pm, and holidays

Union: None

Patient Facing: Yes

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.

• 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.
• Refer 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.