Work as part of a team to conduct initial assessment of participant strengths and needs. Conduct subsequent 90-day assessments. This includes but is not limited to administering appropriate screening and/or assessment tools.
Assist participants, participants’ significant others, and other team members in the development of a services and supports plan, which addresses the participant’s goals and any medical, behavioral health and/or substance use treatment needs.
Assist participants in setting goals related to housing retention, benefits establishment, employment and self-sufficiency, and other topics which support the program participant in gaining more control over their lives and their health.
In conjunction with intensive case management services and each participant, assist with evaluating progress towards goals and make adjustments in the case management plan to facilitate progress toward goals.
Assess participant eligibility/suitability for special programs.
Complete all necessary and required documentation, which includes use of the care management platform.
Maintain participant confidentiality and privacy by protecting participant health and personal information.
Coaching and Social Support
Connect and engage housed participants in activities and services.
Establish a trusting and open relationship with participants.
Accompany participants to appointments as needed and appropriate.
Help participants to build social support systems; this includes connecting participants to support and recovery groups.
Provide coaching for housing, employment, and other interviews and address participants’ anxieties related to these activities.
Care Coordination, Case Management, and System Navigation
Work as part of a team providing intensive case management for a determined period of time.
Provide warm hand-offs and supported referrals to necessary supports and services, including housing, education, employment, substance use treatment, etc.
Engage with participants in most appropriate and accessible location.
Connect participants to needed resources within various health and social service providers.
Arrange or provide transportation to services as needed.
Assist with obtaining, completing, and submitting applications, and appeals processes.
Support participants to prepare for and complete needed medical and social service appointments.
Facilitate connection to and engagement with a geographically and culturally appropriate primary care home.
Arrange for supportive services such as home health care, in home supportive services, or durable medical equipment as needed.
Serve as an advocate on behalf of participants within clinical, public agency, and community-based settings to help participant achieve health and life goals and to secure necessary services and supports, promoting participant’s recovery.
Assist participants to learn to advocate for him/her/themselves.
Use motivational interviewing and popular education to activate the participant to set and achieve personal goals.
Provide connection to appropriate programs, including social service programs and organizations that conduct community building and organizing, to facilitate empowerment, self-determination, and engagement in the community.
Locate assigned clients and secure a safe place for them to stay while working on permanent housing.
Identify and help secure items needed to successfully navigate the housing process including identification.
Build a working relationship with the client based on trust and trustworthiness.
Complete assignments, documentation of services, and other duties as delegated in a competent and timely manner.
Communicate clearly, professionally and effectively with ICMS case manager, and all site-specific colleagues.
Participate in team building efforts to promote positive interpersonal relationships with team members.