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 potential clients referred for Re-Link program to provide initial screening for eligibility
• Complete an intake form for all clients who are eligible to participate in the Re-Link program
• Identify and coordinate level of need pertaining to medical services , recovery services, behavioral health and social services via initial screenings and intakes.
• 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.
See attached position description
NHC performance measure(s) this activity falls under (if any). :
• Deliver Information about Health Insurance, Health Care Access, and Health Benefits Programs
• Health Care Service Enrollment and Scheduling
• Social Service Navigation
• Health Education: Prevention
• Health Education: Disease Management