Street Outreach Care Coordinator - Adult Services - Brattleboro

The Street Outreach Care Coordinator proactively engages individuals experiencing homelessness, housing instability, mental health challenges, substance use concerns, and other vulnerabilities in nontraditional community settings, including streets, encampments, parks, shelters, and other locations where individuals may be living or gathering. Using a trauma-informed, person-centered, and low-threshold approach, the Street Outreach Care Coordinator builds trusting relationships, assesses immediate needs, and connects individuals to medical, behavioral health, housing, and social support services.

This role serves as a critical bridge between vulnerable community members and essential services, helping individuals overcome barriers to care and improve their overall health, safety, and well-being.

• Conduct proactive outreach to individuals in streets, encampments, and other nontraditional settings.
• Build rapport and establish trusting relationships with individuals who may be hesitant to engage with traditional service systems.
• Utilize trauma-informed, culturally responsive, and person-centered and substance use safety planning approaches with clients.
• Provide ongoing outreach and engagement to support client stabilization and service connection.
• Meet clients where they are and support self-determined goals and priorities.

• Conduct initial screenings and needs assessments to identify medical, behavioral health, housing, financial, and social service needs.
• Develop individualized service plans in collaboration with clients.
• Coordinate access to healthcare, mental health services, substance use treatment, housing resources, income supports, and community-based programs.
• Assist clients in obtaining identification, benefits, insurance coverage, and other essential resources.
• Advocate on behalf of clients to reduce barriers to services and support successful outcomes.

• Facilitate referrals and warm handoffs to community partners and service providers.
• Monitor client progress and provide follow-up support to ensure continuity of care.
• Coordinate with healthcare providers, behavioral health clinicians, housing agencies, emergency services, and community organizations.
• Maintain accurate and timely documentation of outreach activities, client interactions, assessments, and referrals.
• Participate in case reviews and multidisciplinary care planning meetings.

• Develop and maintain effective working relationships with community partners, emergency responders, healthcare providers, shelters, and housing organizations.
• Represent the organization at community meetings, outreach events, and collaborative initiatives.
• Support the identification of service gaps and opportunities to enhance community response efforts.

• Knowledge of homelessness, mental health, substance use, housing instability, and community support systems.
• Strong relationship-building and engagement skills with diverse populations.
• Ability to work independently in community-based settings and make sound decisions in dynamic situations.
• Excellent communication, conflict resolution, and problem-solving skills.
• Ability to maintain professional boundaries while fostering meaningful client relationships.
• Strong organizational, documentation, and time-management skills.
• Knowledge of trauma-informed care, substance use safety planning approaches, and person-centered service delivery.
• Ability to work collaboratively within multidisciplinary teams and community partnerships.

• Reports to Assistant Director, HealthWorks ACT
• Interacts closely with HealthWorks ACT staff and clients

• Bachelors in Social Work, Human Services, Community Development, Addictions, Mental Health, Nursing, or a related field preferred.
• Equivalent combination of education and relevant experience may be considered.

• At least one year of experience working with vulnerable or underserved populations.
• Experience in homelessness outreach, community mental health, substance use services, healthcare, case management, or crisis intervention is an asset.
• Experience conducting outreach in community settings and coordinating services across multiple systems is preferred.

• Significant time spent in the community conducting outreach in various weather conditions and environments.
• Regular travel throughout the service area.
• Occasional evening or weekend work may be required.
• Exposure to challenging situations involving individuals experiencing mental health, substance use, housing, or social crises.