CBCM Case Manager

Primary Purpose

Functions as the key linkage between homeless persons with mental illness and the service systems throughout the community. Ensures that clients meet the criteria for community based case management. Responds comprehensively to the needs of clients through ongoing case management. It is expected that clinical supervision will be received internally in order that licensure may be obtained.

• Carry an average caseload of 35 CBCM clients (or no more than 25 CCS clients if unlicensed).
• Document all services provided to authorized CBCM clients based on established acuity levels.
• Provide face‑to‑face direct service contact for clients no less than once per month.
• Provide crisis and emergency services, either by telephone or face‑to‑face, 24 hours per day for clients on the Case Management Team.
• Ensure all individuals who accept and are eligible for case management services are registered with AMHD and/or CCS.
• Conduct intake and assist in assessment, counseling, and referrals for health and social services.
• Provide clients on the Case Management Team with an Individual Recovery Plan within 72 hours of intake and 30 days thereafter; conduct Recovery Plan reviews every 6 months thereafter.
• Conduct outreach in the community and at homeless shelters.
• Assist clients in acquiring emergency supplies, including food, clothing, bedding, medicine and hygiene items.
• Assist clients in applying for entitlements and obtaining identification; take clients through entitlement, medical, and mental health systems to connect them with services and benefits.
• Assist clients with legal entanglements.
• Make appointments for clients and escort them to such appointments as needed.
• Provide counseling, consultation, and crisis intervention as needed; encourage medication adherence as appropriate.
• Work with Housing Specialists to assist clients with housing needs.
• Assist with family and social relationships as appropriate; teach communication and social skills development when needed.
• Provide appropriate case management services for each client, which include:
  • Outreach / engagement / housing needs and home visits
  • Preparing a plan, based on clients' needs and goals, for the provision of services
  • Following up with clients and providers of service to determine outcome of linkages
  • Providing psycho‑social rehabilitation services (teaching hygiene and self‑care, housing skills, budgeting, problem‑solving, etc.)
  • Advocating on behalf of clients to ensure equity of treatment
• Keep records of all client cases and ensure that the records are entered into the clinic computer database; safeguard clients' confidentiality and other rights.
• Work with other Project staff in providing a coordinated system of care to the clients.
• Work as part of a team with other staff for purposes of outreach, back‑up, and shared service delivery.
• Assist other Project staff in obtaining information on clients from other agencies.
• Maintain regular and reliable on‑site attendance.

• Good crisis intervention / de‑escalation skills.
• Training in substance abuse / dual diagnosis.
• Ability to relate effectively to difficult clients, including mentally ill, chemically dependent, and other homeless individuals.
• Ability to operate a vehicle with a valid State of Hawaii driver’s license; must provide proof of automobile insurance and a clean driver’s abstract.
• Strong communication and interpersonal skills.