Recovery Navigator Program - Outreach Case Manager

The Outreach Case Manager provides outreach, long-term engagement, and supportive services for participants through intensive case management activities and collaboration with existing services available through Island County and all other service providers in the county.

Referrals come from individuals and organizations who might encounter an individual who could benefit from the Recovery Navigator program such as law enforcement, community-based organizations, and emergency medical services.

The Outreach Case Manager will provide direct, field-based services to individuals who may have extensive history of psychiatric hospitalizations, are unhoused, have co-occurring substance use disorders, mental health disorders or issues, medical problems, or are involved in the criminal justice system. Services might include helping individuals with housing, parenting, benefits, symptom management, medical care, behavioral health treatment and employment, all performed where those in need are located.

The Outreach Case Manager will provide assessments of individual needs to determine stressors and targeted intervention points to improve the individual’s overall stability and functioning. The Outreach Case Manager will work with Outreach Peer Navigators to ensure immediate field-based response when a referral is made. For individuals who are not interested in accessing SUD and/or mental health services, Outreach Case Managers will focus on regular and ongoing engagement to ensure a relationship is maintained so subsequent support can be quickly addressed.

• Provide outreach and intensive case management services for participants at the referral location to establish a working relationship and offer services.
• Assess participants for severity of chemical dependency and housing status and determine needs for other services.
• Establish communication with appropriate community services such as DSHS, SSI benefits, and behavioral health treatment, to initiate and facilitate the completion of application and enrollment. Meet with community service providers as needed to coordinate and establish services.
• Develop relationships with housing resources and assist the participant in gaining access to appropriate housing and maintaining occupancy.
• Develop and implement with the participant’s input an individualized service plan which addresses the needs of the participant for food, clothing, shelter, and health care and behavioral health treatment. Update this plan periodically with participant to reflect movement toward or attainment of articulated goals and the emergence of new needs.
• Develop and maintain a working relationship with crisis stabilization facilities, crisis responders, evaluation, and treatment facility staff, DSHS workers, behavioral health treatment providers, health care providers, shelter providers, landlords, detox centers, protective or representative payees, and other community programs which may support participants.
• Develop and maintain collaborative relationships with local partners including local law enforcement and fire departments. Provide advocacy and support for participants within the criminal justice system including court appearances and written communication.
• Attend regularly scheduled Operational Work Group Meetings and the staffing of participants with partners.
• Accompany participants to appointments as needed.
• Assist participants in developing a spending plan and in shopping.
• Identify gaps and barriers in available community resources and advocate for systemic changes.
• Attend stakeholder work groups and committees to represent the experiences of program participants.
• Develop and maintain participant files for assigned caseload according to program, contract, and state requirements.
• Follow policies, procedures, and protocols for this program as a member of the Recovery Navigator Program team.
• Document all contacts in a timely manner including face-to-face interviews, collateral and networking contacts, and correspondence. Maintain case records in accordance with standards and requirements. Prepare reports by collecting, analyzing, and summarizing treatment and results data.
• Assist in staffing…