Social Worker – Street-Stabilization Team

Department: HSAO Reports To: Allegheny County Department of Human Services Program Manager Location: Department of Human Services/Community-Based FLSA Status: Exempt / Full-Time

Position Summary:

At the Allegheny County Department of Human Services (DHS), our mission is to improve the welfare of the County’s most vulnerable residents. We operate, influence, and fund essential services worth over $1 billion. More than 200,000 residents each year depend on these services, which include treatment for mental health and substance use disorders, housing and homelessness prevention, and child and older adult protective services. Over the past 20 years, we have built a national reputation for using data and analytics to deliver more effective and efficient public services. Above all, we are convinced that there remain significant opportunities to improve the lives of our clients and for DHS to extend its leadership role in inspiring governments to make similar investments.

The Social Worker (Street Stabilization Team) will join the Justice Collaborations unit at DHS—a team dedicated to advancing public health and community-centered approaches to safety. Justice Collaborations leads efforts to reduce incarceration, improve crisis response, prevent violence, and strengthen reentry supports. As a critical member of the new Street Stabilization Team (SST), which was designed collaboratively with government, hospital and community partners over the past year, this position will work to improve outcomes for some of the most complex and vulnerable residents in Allegheny County.

Street Stabilization Team Background:

There is a subset of Allegheny County residents with a complex set of care needs inclusive of some or all the following: severe and persistent mental illness including severe substance use disorders, lack of housing, extreme poverty, chronic medical conditions, and physical or cognitive disability. While this group of residents has frequent interaction with law enforcement and other first responders, high utilization of crisis services including homeless street outreach, mental health crisis providers, emergency department visits, involuntary psychiatric hospitalizations, and jail, their chronic needs remain unaddressed and crises persist.

In response to this gap, Allegheny County Department of Human Services is piloting the Street Stabilization Team (SST). SST is a multidisciplinary, street-based outreach team led by a psychiatrist and focused on engaging and serving a cohort of 20–30 unhoused participants who have not successfully engaged in traditional treatment supports due to the severity of their behavioral and other health needs. The Social Worker is a core member of the Street Stabilization Team.

The Social Worker will use a harm reduction approach to working with SST participants. They will provide persistent community-based outreach, engagement, assessment, care coordination, crisis intervention, and advocacy services. They will collaborate closely with the SST’s dedicated street psychiatrist (contracted through UPMC’s Western Psychiatric Hospital) and street nurse (contracted through Allegheny Health Network’s Center for Inclusion Health) on the multi-disciplinary team as well as with other providers to ensure intensive, holistic, person-centered care in non-traditional settings. The Social Worker is an employee of HSAO working for and reporting to the SST Program Manager at Allegheny County DHS.

Key Responsibilities:

• Comprehensive Record Review: Participate in comprehensive record reviews for all participants assigned to the Street Treatment Team.
• Engagement and Outreach: Conduct field-based outreach to members of the cohort. Expect to spend a significant portion of time outdoors and in the community. This includes going to encampments, shelters, hospitals, jails, and public spaces. They will use harm reduction and trauma informed approaches to build rapport with individuals ambivalent or resistant to services.
• Case Management:
  • Provide intensive person-centered case management services including assessments, service planning, advocacy, and care coordination.
  • Connect participant to appropriate resources, referral to treatment, recovery supports, primary care, and public benefit programs.
  • Collaborate with housing systems and shelter providers to assist in identifying and maintaining housing.
• Clinical Support:
  • Conduct biopsychosocial assessments and guide treatment goals and interventions
  • Coordinate with various providers regarding participant care to ensure smooth transitions and improved clinical outcomes
  • Provide psychoeducation, supportive counseling, and skill-building interventions and interpersonal relationship development.
• Collaboration and Teamwork:
  • Contribute to collaboratively developed participant assessments and treatment plans as part of a multidisciplinary, multi provider team directed by the Department of Human Service program manager and clinically led by Western Psychiatric Hospital Street Psychiatrist.
  • Collaborate and support participants when engaging with mental health, physical health, and criminal justice systems, specifically, when the participant engages with emergency system to provide collateral information, continuity of care, and support discharge planning.
  • Participate and present in system stakeholder meetings, share observations, make recommendations and adjust strategies as needed in collaboration with the DHS' SST Program Director.
  • Establish expertise in Allegheny County’s human service resources with specific focus on behavioral health and housing resources and support recommendations and referrals to appropriate service options
• Documentation and Reporting:
  • Social Workers will enter quantitative and qualitative data about SST referrals and participants in established data management systems. They will maintain timely records of interactions and activities for the purpose of tracking and measuring process and outcome metrics and developing a sustainable structure for SST to bill to Health Choices following a pilot period.

Required Qualifications:

· Experience/Education:

•  Master’s degree in social work (MSW) from an accredited institution or similar/equivalent degree or a Bachelor's degree with a Minimum of 3 years of experience working with individuals with SMI, SUD, and/or experiencing homelessness.
• Experience in harm reduction, and trauma-informed care.

· Skills:

• Strong clinical assessment, case management, and crisis intervention skills.
• Comfort and facility with trauma-informed, verbal de-escalation techniques
• Effective verbal and written communication
• Strong triaging and ability to prioritize tasks in high need, resource limited settings
• Ability to take initiative while working collaboratively and in non-traditional settings.
• Commitment to equity, inclusion, and reducing stigma.

Preferred Qualities:

• Lived experience and/or deep understanding of homelessness, recovery, and mental health systems.
• Flexibility, resilience, and a deep commitment to social justice.