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Outreach Caseworker

Boston Medical Center (BMC) is more than a hospital. It´s a network of support and care that touches the lives of hundreds of thousands of people in need each year. It is the largest and busiest provider of trauma and emergency services in New England. Emphasizing community-based care, BMC is committed to providing consistently excellent and accessible health services to all--and is the largest safety-net hospital in New England. The hospital is also the primary teaching affiliate of the nationally ranked Boston University School of Medicine (BUSM) and a founding partner of Boston HealthNet - an integrated health care delivery systems that includes many community health centers. BMC provides a full range of pediatric and adult care services, from primary to family medicine to advanced specialty care.

BMC is also committed to our employees, who are a very important piece to who we are. We pride ourselves in providing equal employment opportunity and non-discrimination for all employees and qualified applicants without regard to a person's race, color, gender, age, religion, national origin, ancestry, disability, veteran status, genetic information, sexual orientation or any characteristic protected under applicable law. BMC will make reasonable accommodations for qualified individuals with known disabilities, in accordance with applicable law.

This position is a special role designed for the Public Health programs. This position is for a caseworker who is conducting their services almost entirely in the field and not at the hospital. The Public Health Outreach Caseworker (PHOC) will work will work across all programs and interventions primarily to outreach and engage and re-engage clients into HIV care. Performs outreach, conducts home visits, and works with clients therapeutically in their community locations. The PHOC will work directly with the HIV Intake Coordinator for all newly diagnosed HIV patients and those returning to care. The PHIC will typically have the primary responsibility of following clients who have either been newly diagnosed with HIV or have fallen out of HIV care from BMC for a period of time until they are deemed ready to link back into medical case at BMC. They will work with the medical providers, the Intake Coordinator, and program management to ensure that these positive patients receive appropr iate services such as mental health and substance abuse assessments, risk reduction, partner notification services, further testing, needs assessments, MDPH/CDC/BPHC funded interventions, and any other necessary services. Through individual intervention, provide ongoing therapeutic services and referral services to clients in their community locations. Logs all data in relevant systems and writes notes in the EMR. Collects data for program evaluation, conducts chart reviews in the EMR, tracks data and follows-up with relevant parties. Conducts all activities within the standards and regulations of the Boston Public Health Commission (BPHC), Massachusetts Department of Public Health (DPH), Center for Disease Control and Prevention (CDC), and any other funders.

Medical Case Management/Mental Health

  • Provides advocacy and therapeutic services for HIV-infected patients, especially mental health counseling in the field
  • Assesses patient and family to ascertain those emotional and social problems, and identifies those issues which must be which must be addressed during the patient's care, and formulates plan
  • Links patients to a broad range of services, including, but not limited to, HIV support services, substance abuse treatment, financial assistance, housing, food, financial entitlements, clothing, transportation, adherence and prevention counseling, and harm-reduction programs (addresses concrete service needs and encourages engagement into systems as needed).
  • Monitors patients' progress via patient's level of functioning, adherence to treatment plans, recovery/relapse process and/or service needs.
  • Assists with scheduling initial intake visit, follows up until linked to medical care
  • Provides education, counsels, and supports client individually and in groups. Uses a variety of culturally, linguistically and educationally appropriate strategies, in a variety of settings. Coordinates with Interpreter Services, as needed.
  • Develops and maintains strong relationships with the community and resources to ensure patient access.
  • Assists with immigration and refugee issues; works with refugee services for coordination of concrete services and support as needed.
  • Collaborates and coordinates with health care team members to promote positive prevention & harm reduction.
  • Performs initial psychosocial intake for assigned new patients as well as follow-up assessments.
  • Assesses patients' needs and develops flexible mental health service plans and maintains regular updates of these plans, as needed.
  • Conducts comprehensive and ongoing mental health assessments and engages patients in risk reduction and positive prevention discussions and activities.
  • Addresses concrete service needs and encourages engagement into systems as needed.
  • Links patients to a broad range of services, including, but not limited to: HIV support services, including community-based case management; substance abuse treatment; mental health services; financial assistance; housing; food; financial entitlements; clothing; and transportation.
  • Monitors patients' progress via patients' level of functioning, adherence to treatment plans, recovery/relapse process, and service needs.
  • Develops and maintains strong relationships with community resources to ensure patient access.
  • Assists with immigration and refugee issues; works with refugee services for coordination of concrete services and support.
  • Assists with interpreter scheduling/coordinating.
  • Links program patients into medical care and other services
  • Deliver HIV positive test results directly to patients
  • Communicate effectively, professionally, and in a timely manner with providers
  • Work closely with the BMC lab and the MDPH state lab & DIS when necessary
  • Conduct needs assessments and refer patients into care and services
  • Must be able to travel across the BMC campus and throughout the city of Boston to community outreach sites
  • Effectively work in a team with community outreach sites and within BMC
  • Must be able to respond spontaneously and immediately when notified about positive results or assigned by management to those cases
  • Write accurate notes in the BMC EMR and in the other tracking systems for a specific contracts
  • Follows-up with relevant providers as needed
  • Responding to the EMR messaging system in a timely manner
  • Must be able to write and communicate in a professional manner appropriate to a major hospital
  • Has a knowledge of HIV/HCV/STIs and able to communicate appropriate information to patients and providers
  • Able to conduct chart reviews in the EMR to make decisions about the linkage to care process
  • Collects all programmatic data
  • Performs and maintains all documentation in the electronic chart of patient encounters; resource development efforts; and other patient interventions and interactions, utilizing service codes for all such documented activities.
  • Able to input data into computer systems, including the BMC EMR
  • Able to think critically and logically when handling patient information, particularly around newly diagnosed HIV
  • positive patients
  • Respond in a timely manner to deadlines and program management
  • Responsible for following up on any cases until there is a resolution
  • Tracks and monitors referral from various client referrals sources.
  • Be able to report basic level data to program management


  • Masters Degree
  • Maintain clinical license
  • Attends all necessary trainings to become proficient in prevention and education methods and for continuing maintenance of proficiency. Maintains established department standards for prevention and education service delivery
  • Distributes prevention materials (pamphlets, condoms, bleach kits, etc.) to target populations in the field
  • Attends meetings as requested by the program manager to represent BMC as needed. Attends staff meetings and communicates progress and problems to Program Manager. Attends clinical supervision staff support group. Participate in regular HIV prevention program implementation team meetings. Participate in CDC/MDPH/BPHC meetings with other grantees if requested.
  • Remains knowledgeable of, and follows, appropriate policies, procedures, and work standards, including but not limited to, those regarding hours of work, absenteeism, and tardiness.
  • Maintains competency in appropriate areas of responsibility to ensure quality of care. Maintains patient confidentiality; is comfortable handling sensitive personal information. Follows established hospital infection control and safety procedures
  • Utilizes hospital values as basis for decision making and to facilitate BMC missions. Models the ability to set professional boundaries.
  • Performs other duties as assigned or as necessary.
  • Must adhere to all of BMC's RESPECT behavioral standards.

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Search for "outreach caseworker"
Job ID 2201357