Case Manager

The Homeless Outreach Team (HOT) pairs a behavioral health clinical partner with a dedicated City of Mobile law enforcement officer in a shared HOT vehicle, working side-by-side to locate, engage, and connect people experiencing unsheltered homelessness to the services and housing they need. The model is adapted from Houston's nationally recognized Homeless Outreach Team — in operation since 2011 — which pairs Houston police officers with mental health case managers to conduct relationship-based street outreach to the chronically homeless, with the explicit goal of reducing the number of people living on the street by helping them overcome the personal and systemic obstacles keeping them there.

This is not a single-visit service model. The clinical partner and officer spend their days together, returning to the same individuals and encampments repeatedly over weeks and months, building the trust required to move someone from the street into documentation, benefits, treatment, and ultimately housing. As in Houston's program, the team's effectiveness depends on “shepherding” each person through a complex, multi-agency system — not simply referring them and moving on.

• Ride daily with an assigned City of Mobile law enforcement officer in the HOT vehicle to proactively locate, visit, and engage individuals and encampments throughout the assigned area.
• Conduct repeated, relationship-based outreach visits — recognizing that trust with chronically unsheltered individuals is built over multiple contacts, not a single encounter.
• Maintain a working map/roster of known encampments and individuals, updating status, needs, and engagement history after each contact.
• Provide crisis de-escalation and initial behavioral health assessment in the field when needed, coordinating with AltaPointe's crisis system for higher-acuity situations.

• Assist individuals in obtaining foundational documents (state , birth certificate, Social Security card) required to access nearly every downstream benefit or housing program.
• Help individuals apply for and maintain public benefits (Medicaid, SSI/SSDI, SNAP, VA benefits for veterans, and other applicable entitlements).
• Transport or accompany individuals to HOPE for All Gulf Coast to complete the Coordinated Entry assessment (VI-SPDAT or successor tool), the required first step toward HUD-funded permanent supportive and rapid re-housing programs.
• Connect individuals to primary healthcare, psychiatric care, and medication management — including direct linkage to AltaPointe outpatient, crisis, and prescriber services — and provide follow-up support to sustain treatment engagement and medication adherence.
• Follow up after every referral. A warm hand-off is the beginning of the case, not the end of it — track whether the appointment was kept, the benefit was approved, or the housing application progressed, and problem-solve when it doesn't.

• Work jointly with the assigned officer and City partners to identify encampments and prioritize outreach based on size, risk, and duration.
• Pursue encampment resolution through service connection and housing placement as the primary strategy — the goal is not simply to clear a location, but to ensure every individual present has been engaged, assessed, and connected to an appropriate resource before any site closure.
• When an encampment sits on private property and closure is directed by the property owner or the City, support the process in a humane, individualized way ensure each person has had genuine access to services, storage or retrieval options for belongings, and, where possible, an alternative before the…