Case Manager II - Destiny In-Custody (Case Management) and Enhanced Care Management (ECM)

CalAIM, a Department of Health Care Services (DHCS) initiative, aims to improve Medi-Cal recipients' quality of life and health outcomes through system reforms. It introduces members to CalAIM within the Destiny In Custody program and follows them through their transition back into the community through Enhanced Care Management (ECM), a statewide Medi-Cal Managed Care Plan (MCP), that offers the person-centered, community-based highest care management tier within the Medi-Cal MCP Population Health Management continuum.

The Case Manager II provides comprehensive case management services for inmates in Solano County. Case Manager II will provide information, support, and follow-up services as needed and as identified in the Re-entry Plan. Case Manager II will address needs including but not limited to sober living and transitional housing, stable housing, employment and/or (re)establishment of entitlement benefits, family reunification and counseling, mental health and SUD treatment and ongoing recovery, finding childcare, and vocational training, rent subsidies, deposit assistance, civil legal services, gender specific mentoring, clean slate services, and subsidized employment and transportation to appointments. Once released, the Case Manager will continue to work with the participant by meeting them wherever they are: on the street, in a shelter, in their provider’s office, or at home to coordinate their health-related care and services, ensuring a holistic approach to their well-being.

KEY RESPONSIBILITIES

Pre-Release Planning

Develop a Re-entry Plan for each participant in the In-Custody Case Management program.

The development of such a plan allows for the smooth transition of participants in the community and decreases the likelihood of recidivism.

This will include the development of transitional housing (when possible), linkage to community resources, and linkage to probation, parole, or other stakeholders in the community.

Post-Release Treatment

Link participants with behavioral health services, or health care treatment services, which may include outpatient substance use disorder treatment, medication-assisted treatment, individual therapy, rehabilitation groups, and/or health care visits with a goal to help with life skills development and ongoing support in the community. Maintain regular contact with all providers involved in the client’s care team.

Ensure continuous and integrated care among all service providers.

Follow up with primary care, mental health, substance use disorder treatment, and necessary community-based services for ongoing care coordination.

Collaborate with participants and their families for community reintegration.

Collaborate with outside agencies to obtain needed community resources (housing, sober living, substance abuse recovery agencies, medical facilities, employment/education agencies, DPSS, DMV or other needed resources).

Communicate collaboratively with all members of the behavioral health team.

Pre-Release and Community-Based Case Management

Initiate in-custody case management with participants to begin re-entry plan implementation, pick participants up from jail, provide court advocacy (when necessary), provide assistance with support network development and linkage to necessary services at varying levels of intensity (based on participant need).

Incentives

Provide barrier removal incentives to assist with participants' transition back into the community.

Barrier removal incentives include, but are not limited to, clothing to wear upon release, hygiene items, and fees for identification documentation.

The Case Manager is responsible for providing a case management approach that will be assessment-driven, collaborative, strength-based, gender-responsive, and client-centered. Responsibilities include but is not limited to:

Conduct intakes and assessments.

Work with clients to create, track, revise, and update client-focused Individual Re-Entry Plans drawing on an integrated array of public, private, and project-specific resources.

Partners with the County’s Housing Navigators to ensure that all homeless clients receive immediate, individualized housing-related support, including accelerated access to a shelter bed.

Following initial re-entry plan development, the case manager will meet with each client every two weeks at a minimum. On a case-by-case basis, more frequent contact will be arranged to address emerging needs or client crises.

Responds to inmate requests as needed or as assigned by the Program Manager.

Responsible for tracking outcomes and providing regular reporting to the Program Manager as requested.

Case Managers will follow clients during their entire SUD Subsidized Housing episode, assisting with the transition as clients “Step Down” to different levels of care.

Documentation Responsibilities:

Document participant interactions in the Welligent platform within 24 hours of service delivery.

Completes all supporting documentation, including, but not limited to, assessments, care plans, re-entry plans, and individual change plans, and discharge paperwork/process in accordance with contract timeframes.

Works with participant and other available internal and external resources to develop/maintain care plans, progress notes, and appropriate updates in support of health and recovery needs for the participant.

Community-Based Responsibilities

Meet ECM participants at their physical locations and cater to their individual needs.

Conduct care management activities in locations most attainable and desirable for clients.

Represent HR360 at various community outreach events to engage potential members and educate community partners.

Conduct screenings for ECM eligibility and facilitate enrollment into the ECM program.

Submit mileage for field-based care management activities for reimbursement.

QUALIFICATIONS

Education, Certification, Experience

High School Diploma or GED + AOD Registration/Certification.

or

Bachelor's Degree + 2 years Case Management experience.

Must be willing to work a hybrid on-site (70%) and field-based role (30%)

Desired

Experience with Electronic Health Records (EHR) systems is preferred.

Experience working successfully with issues of substance abuse, mental health, criminal background, and other potential barriers to economic self-sufficiency preferred.

Experience working with child welfare systems preferred.

Experience working with criminal justice population preferred.