Clinical Case Manager And Health Integration Pathway

Description

Clinical Case Managers on The Housing and Health Integration Pathway Expansion team will provide mental health and housing stability case management services to unhoused individuals engaged through the CTA Safe Riders program. The CTA Safe Riders program is a collaborative project between the CTA, Housing Forward and other local community social service agencies to address the needs of the multiple unhoused individuals riding and sleeping on or near the CTA trains and stations.

The Housing and Health Integration Pathway program offers individuals up to twelve months short-term transitional shelter housing paired with mental health and case management services while working towards permanent housing placement. The program supports participants with services aimed at securing sustainable income, building long-term support networks, and connecting to ongoing community-based mental health care.

The Clinical Case Managers will be the primary client relationship manager and contact. They will work with the client to identify service needs and goal achievement, maintaining the client relationship and service activities toward goal attainment until the individual is determined to be connected to community based mental health supports and stably housed, care is transferred to another provider, or if the individual chooses not to continue services.

• Assess clients referred to HHIP Expansion through the Safe Riders program to determine eligibility, level of interest and commitment to participate in the program.
• Meet with HHIP Program Manager and Behavioral Health Specialist to identify and enroll assessed participants for program openings.
• Performs comprehensive, in-depth assessments of clients in the program identifying immediate barriers to mental health stability and finding permanent or long-term housing within 90 days of placement.
• Develop a service plan to address those barriers and to ensure success in connecting with ongoing community mental health and medical management support and finding permanent housing.
• Serves as primary case manager to a caseload of up to 15 clients in the program by ensuring that clients have access to a full range of counseling, advocacy, educational, and case management services either through direct delivery of services or through referrals.
• Have a minimum of one contact per week with clients, and more if indicated. At least two contacts per month should be a home visit to assess their progress in maintaining independent living and carrying out activities of daily living.
• When indicated, schedules, coordinates and transports clients to appointments including medical assisted treatment, andother program related services.
• Respond to behavioral crisis situations as needed and in consultation with supervisor, senior management and Behavioral Health Specialist, develop and execute appropriate intervention including involuntary psychiatric hospitalization.
• Work with housing navigators to ensure that clients have basic household furniture and items to maintain independentliving.
• When indicated, the case manager will work with the Benefit Coordinator to ensure that clients apply for Social Security and other appropriate government sponsored benefits.
• When necessary, refers clients and supports attendance to appropriate community support groups (AA, NA, NAMI, Ascension peer group, etc.)
• Refers clients to appropriate WRAP services and other Housing Forward programs as indicated.

• Establishes referral network/linkages with outside agencies for participants.
• Represents and interprets the program to the community at large.
• Participate in meetings with the partners in this project and provide information to ensure appropriate communication among partners.

• Takes a proactive role in the development of services and programming that addresses the goals and metrics of the program.?
• Complies with agency record-keeping expectations including timely entries of client contact and case notes in HMIS and other client tracking systems.
• Assists in the preparation of narrative and quantitative reports
• Atte…