Housing & Health Coordinator - Older Adults Specialist

Chicago House empowers persons living with or vulnerable to HIV/AIDS to lead healthy and dignified lives, through housing and compassionate, client-centered support services.

Chicago House recognizes that Black, Indigenous, and People of Color (BIPOC), LGBTQ+ individuals, and/or People with Disabilities are systemically limited in their practice, opportunity, and exposure to develop learned expertise. Chicago House values both learned expertise and lived experience. We take a holistic review of applicants, and we strongly encourage marginalized groups to apply.

The Housing & Health Coordinator
- Older Adults Specialist (HHC-OAS) resides within the Housing & Health Navigation department and is a part of the Centralized Intake team. They will employ an integrated housing navigation and care management service delivery model to improve housing and health outcomes for people living with HIV, above the age of 50. The HHC-OAS is part of a team that works in conjunction with service providers at Chicago House and external medical providers.

The HHC-OAS furthers an aging in place approach to improve housing and health outcomes for older adults, focused on navigating pathways to short- and/or long-term housing. Comprehensively, they will be addressing the multiple barriers related to social determinants of health to support becoming stably housed.

• Provide short-term, intensive case management services around housing navigation to unstably housed, older adults (ages 50+), with a caseload size determined by the Centralized Intake & Housing Manager, within a range of 50 clients at any point in time.

• Specifically, the HHC-OAS will assist with the following:
  • Conduct intakes and assessments to identify and respond to participants' barriers to housing stability.
  • Develop and monitor the goals identified in the Individual Service Plan with regard to housing pathways and other social care services that address housing barriers, with an emphasis on housing information services, permanent support housing placement, and provision of short-term rental mortgage and utility assistance (STRMU)
  • Implement participants' Individual Service Plan related to housing via eligible enrollments into the Coordinated Entry System, affordable housing searches and referrals to Medicaid waiver 1115 housing opportunities, emergency shelters, IPV shelters, and rapid re-housing programs.

• Provide crisis prevention and intervention services for unstably housed and homeless community clients.
• Meet with participants who need immediate short-term, intervention case management regarding housing.
• Assist participants in the community until they obtain and maintain safe affordable housing or to navigate current housing options as available.

• • Implement participants' Individual Service Plan related to benefits by providing referrals to benefits navigation to assist them to obtain Medicaid/ACA, Medicare, Marketplace insurance, SNAP, and other benefits which they might qualify.
  • Work in coordination with other medical-based social service staff to support access with retention in care, such as mental health/substance, legal services, vital record navigation, resource navigation, and Pharmacy+Benefits.
  • Refer participants with complex and ongoing needs who need long-term supports, including case management, to Permanent Supportive Housing or other forms of case management.

• Follow-up with participants and their service providers regarding outcome of referrals.
• Assist with scheduling and preparing for housing-related appointments, including arranging transportation to and from appointments.
• In collaboration with medical and community-based health workers, complete and facilitate discharge of clients that includes the development of an aftercare plan and retention in medical and social care to support ongoing housing stability.

• Create and maintain resource and referral networks, with a specialized focus on services for older adults.

• Provide ongoing and professional communication with participants' treatment providers (e.g. CH Older Adult Services Team, Occupational Therapist Consultant, Infectious Disease provider, social worker, medical case manager), including participation in case conferences.
• Ability to build relationships and networks with other CBO's and medical facilities.
• Maintain comprehensive documentation and reporting on participants and retention-in-care activities in electronic health records.
• Practice harm reduction, trauma-informed, and LGBTQ-affirming strategies with participants.
• Adopt and implement continuous effective engagement strategies throughout intervention period, such as texting and home visits, to maintain participants' participation in program and evaluation activities.
• Collaborate with care managers, medical case managers, and interns in the ongoing development and evaluation of the…