Bhsi Case Manager

• Boston Healthy Start Initiative (BHSI) is a federal grant program designated to the Boston Public Health Commission (BPHC), aimed at providing enhanced support to pregnant and parenting women, children, and families. It offers care coordination, resource connections, health education, and advocacy.
• The CSW/FP will engage with potential participants from Codman Square Health Center's (CSHC) targeted population during their initial prenatal visit. They will assess the risk status of each woman and enroll self-identifying Black pregnant and postpartum women who are at the highest risk of adverse perinatal outcomes into the BHSI program.
• Primary Responsibilities:
• I. Outreach
• Provide outreach and education to eligible women/participants.
• Attend prenatal registration session to recruit and retain a caseload of at least 50 pregnant participants, a combination of 50 postpartum women and children (up to age 18 months), and a minimum of 20 fathers (through coordination with Healthy Start Systems’ Father Friendly Initiative). 
• Participate in BHSI and outreach events with CSHC and BPHC.
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• 2. Patient services
• Obtain consent from patients eligible for enrollment in the BHSI services and data system. Including the National Healthy Start Evaluation as required.
• Complete comprehensive enrollment and assessment protocols for each BHSI enrolled participant.
• Create and monitor a service plan for each enrolled BHSI participant. Reassess and respond to changes as needed.
  • Collaborate with BMC and Brigham and Women's Hospital providers at CSHC.
  • Provide ongoing support to participants that encourages healthy behaviors that increase their perinatal health knowledge, and gain self-confidence, self-sufficiency, and the ability to advocate for themselves and their families.
  • Conduct occasional home visits to BHSI participants as needed.
  • Refer all BHSI clients whose screening suggests possible depression to the Behavioral Health Dept for further testing and treatment.
    • Direct eligible BHSI participants to the BHSI Behavioral health services, under the guidance of the BHSI Behavioral Health Clinician for individual or other relevant behavioral health services.
• Work collaboratively with the BPHC’s Healthy Start Systems Division (HSS) team to deliver client and family-centered prenatal, post-partum, and inter-conceptional care coordination. This includes:
• Attend regular meetings with the perinatal case management team, which should include an assigned BPHC Healthy Baby, Healthy Child Public Health Nurse.
• Referral of BHSI participants (up to 8 weeks postpartum) to Welcome Family (a universal, newborn nurse home visiting program through the MA Dept. of Public Health) in the prenatal period.
• Referral of at least 20 fathers or male partners to the Father Friendly Initiative.
• Attend required BHSI meetings and training.
  • Attend monthly BHSI Program meetings.
  • Attend quarterly BHSI Community Action Network (CAN) meetings.
• Attending perinatal team meetings ad hoc.

High school graduate with experience in working with families and children. Willing and able to work with diverse populations. Must possess sensitivity to the needs of the client population. Ability to work effectively in a team, manage time well, set priorities, achieve concrete goals, and identify areas for program improvement desired. Spanish, French, and/or Haitian Creole preferred.

Other duties and committee responsibilities as requested.