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Boston Health Care for the Homeless Program Manager of Care Tranisitions in Boston, Massachusetts

Your time at work should be fulfilling. Rewarding. Inspiring. That is what you?ll find when you join Boston Health Care for the Homeless Program (BHCHP). At BHCHP over 12,000 men, women, and children experiencing homelessness are seen each year. We are committed to ensuring that every one of these individuals has access to comprehensive health care, from preventative dental services to cancer treatment. You will find challenging and satisfying work every day alongside people who share the same drive and compassion as you do.

We are seeking an individual with an interest in transitions of care to join our Medical Respite team at Boston Health Care for the Homeless Program. Medical Respite at BHCHP consists of two separate programs, each with a different model of care, that together encompass 124 beds for homeless men and women too sick for street or shelter. This position will work with both clinical and non-clinical staff to focus on developing safe discharge plans for patients admitted to one of these two programs. Specifics duties include but are not limited to:

Essential Duties:

  • Supervising the floor case management staff to coordinate safe discharges for patients admitted to Medical Respite including

  • Discharge from Barbara McInnis House to Stacy Kirkpatrick House

  • Discharge to skilled nursing facility (completes MDS forms if needed)

  • Discharge to SUD treatment

  • Discharge to rest home

  • Discharge to housing

  • Discharge to shelter/street

  • Works with Barbara McInnis House leadership to oversee length of stay for both medical respite programs and helps the BMH/SKH team problem-solve complex cases when appropriate.

  • Ensures that the post-discharge clinical pathway is followed and completed for patients who come to McInnis House after inpatient hospital stays.

  • Provides oversight for patients involved with the Behavioral Health Community Partner (BHCP) and Social Determinants of Health (HUB) programs who are admitted to BMH or SKH.

  • Responsible for ensuring that prompt communication occurs between inpatient and outpatient care teams for patients admitted to BMH.

  • Ensures completion of the appropriate care transitions metrics (medication reconciliation, post-discharge follow up) when appropriate

  • Completes a post-discharge phone call with patients within 72 hours of leaving BMH. Documents the result of this call in the clinical chart and communicates any issues to the primary care team.

  • Tracks and reviews specific metrics related to care transitions at BMH.

  • Documents in the medical record as appropriate

  • Other duties as to be determined

    Qualifications:

  • BA/BS required. RN with case management experience strongly preferred.

  • 2 years of social service case management, home care, or community health center experience in a supervisory capacity strongly preferred

  • Excellent communication skills, oral and written

  • Detail-oriented with the ability to multi-task

  • Ability to work well with patients with complex medical problems

  • Supervisory experience preferred

  • Familiarity with local resources preferred

  • Background in data analysis (Microsoft Access or Excel) preferred

    Does this amazing opportunity interest you? Then we'd love to hear from you.

    An Equal Opportunity Employer.

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