Homeless Outreach Specialist

Responsibilities include but are not limited to:

Serve as the primary point of contact for individuals experiencing homelessness who are high utilizers of hospital services or at high-risk of readmission.

Engage with patients during their hospitalization offering emotional support care coordination and assistance with connecting to community resources post-discharge.

Work collaboratively with the interdisciplinary healthcare team to assess patient needs and develop individualized care plans to support patients in their transition from the hospital to the community.

Provide follow-up care in various community settings including shelters homeless outreach sites and medical offices.

Facilitate connections to medical mental health and substance use services to support ongoing care and prevent readmissions.

Collaborate with community organizations shelters and other service providers to ensure patients have access to necessary resources and services to improve their health and stability.

Advocate for patients� needs and ensure connection to services to promote long-term stability and health.

Document all interactions and maintain accurate up-to-date case files in accordance with department policies.

Maintain patient related data tracking systems including Homeless Management Information System (HMIS).

Assist with patient transportation as needed and appropriate.

Bachelor�s degree in social work human services or a related field (or equivalent experience).

Knowledge of healthcare delivery systems social services mental health substance use issues and the challenges faced by individuals experiencing homelessness.

Strong analytical skills to assess patient needs develop care plans and coordinate services.

Excellent interpersonal skills with the ability to interact effectively with patients families healthcare professionals and community organizations.

EXPERIENCE:

At least two years of professional experience in a healthcare setting human services or related field preferably working with individuals experiencing homelessness or underserved populations.

Must be able to build rapport and maintain positive collaborative relationships with patients families and multidisciplinary teams.

Must demonstrate knowledge and skill necessary to provide care to patients throughout the life span with consideration of aging processes human development stages and cultural patterns in each step of the care process.

A basic proficiency in the use of Microsoft office software programs including email Outlook calendar and basic keyboard skills are also required.

Knowledge of the HMIS system preferred.

WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS:

General hospital environment with occasional stressful conditions associated with patient care.

Community and home visits required.

Must be able to make hospital rounds through various patient care areas either by walking or through some other mobile means.

Must be able to lift and or carry up to 10 lbs. to transport items from one patient care unit to the next.

Must maintain a valid driver�s license to operate a motor vehicle. Be able to provide current registration and insurance.

INDEPENDENT ACTION:

Performs independently within the department�s policies and practices. Refers specific complex problems to the director or designee when clarification of the departmental policies and procedures is required.

SUPERVISORY RESPONSIBILITY:

None