CARE COORDINATION

Priority referrals are:

• Assisted Outpatient Treatment (AOT) Referrals
• High users of psychiatric inpatient and CPEP services
• Jail or prison discharges
• Individuals who are homeless
• Individuals with 2 chronic medical conditions

The role of the SIBN Care Coordinator include the following responsibilities:

• Review of the individual’s clinical history, life goals, service needs, and goals for participation in services.
• Collaborate with both consumer and provider (s) in the development and implementation of an Individualized Service Plan (ISP) and crisis plan based upon the consumer’s chosen goals.
• Monitor both the utilization and efficacy of the service package on an ongoing basis and actively work with both the consumer and provider in revising the ISP when indicated.
• Assure ongoing assessments of client goals, strengths, and skill deficits.
• Determine resources that will meet the need identified in the assessment process.
• Coordinate and integrate a written service plan in cooperation with clients.
• Facilitate service delivery.
• Coordinate treatment plans with service providers.
• Assure the maintenance of case management records.
• Provide services that prevent or resolve crisis in order to prevent unnecessary use of emergency rooms and inpatient services
• Provide medication education.
• Assist clients in learning to use fiscal resources.
• Provide community support and education.
• Provide wraparound funds for everyday purchases.

CLIENTS NEED TO HAVE ACTIVE MEDICAID TO RECEIVE THESE SERVICES