Care Coordinator - Street Team

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.

Our dedicated clinical and non‑clinical staff work hard to bring the mission alive. The central focus of that mission is the care of those individuals who avoid shelters and sleep on the streets. This population suffers very high mortality rates and presents a complex burden of co‑occurring medical, mental health and addiction problems that place them at great risk. Living throughout the year on our city’s streets, this group is exposed to the extremes of violence and weather and are among the highest users of emergency medical services.

Hours:

Full‑time, Monday‑Friday; 08:30am – 5:00pm
Union:
Yes (1199 SEIU)
Patient Facing:
Yes

Boston Health Care for the Homeless Program Street Team is seeking a full‑time Care Coordinator to join our multidisciplinary team. In this role, you’ll work with an integrated and multidisciplinary primary care team that seeks out the men and women of our city who live unsheltered, offering both urgent and ongoing medical and behavioral health care. The ideal candidate is flexible, compassionate, and self‑motivated with a strong commitment to serving vulnerable populations.

This role requires delivering low‑threshold, high‑quality care coordination in nontraditional settings such as streets, encampments, and community locations. Because you’ll be practicing on the streets, you can walk more than five miles a day in varying weather conditions.

The Care Coordinator will be responsible for providing case management and care coordination for a panel of adults with a history of chronic unsheltered homelessness, including a subset of high‑risk patients enrolled in the Behavioral Health Community Partners Program. This work includes completing required assessments and documentation based on insurance and program requirements, while working closely with the Street Team to address barriers to health care with a strong focus on social determinants of health.

• Provide outreach‑based care coordination and non‑judgmental support in collaboration with other Street Team members
• Engage individuals experiencing substance use disorders and mental health conditions using low threshold principals and trauma‑informed care practices
• Conduct health and needs assessments and collaborate with patients and the primary care team to develop and implement integrated care plans
• Assess social determinants of health (e.g., housing, food access, benefits, transportation) and support patients in addressing these needs based on their goals and priorities
• Coordinate as needed with outreach and housing partners to address social determinants of health for shared patients
• Track patient appointments, referrals, and primary care; follow up with patients to support appointment adherence or rescheduling when appointments are missed
• Conduct street outreach and home visits…