Program or Project:
Care Outreach & Coordination
Percentage of time over term member will spend with this program:
The member will provide support to 2 medical case managers in the Prison Linkage Program; through an assessment, they have identified clients who suffer with a chronic condition (including diabetes and hypertension) who are in need of additional care outreach and coordination services, following reentry into the community after incarceration. The member will: Meet with client to identify and coordinate level of need pertaining to medical services, recovery services, behavioral health and social services, in conjunction with Medical Case Manager; Conduct regular, ongoing follow up with clients, to document and monitor progress and participation in relevant programs and services; Maintain accurate records and documentation of services provided; Conduct outreach, via phone calls and letters, to clients identified as lost to care to support reengagement. Provide information, education, and practical assistance to clients and members of their support system as required.
Member will identify and coordinate referral services for 20-40 clients every 4 months, for a total of 50-100 clients during the service term.