Serves as the primary point of contact for the Member, Member’s family, Authorized Representative (AR), caregiver, other authorized support person(s) as appropriate, and the multidisciplinary care team providing care to the Member. Assesses member needs in the areas of physical health, mental health, substance use, community-based Long Term Services & Supports (LTSS), oral health, palliative care, trauma-informed care, social supports, and housing as appropriate for individuals experiencing homelessness. Develops a comprehensive Care Management Plan with input from a multidisciplinary care team, as well as the member, to ensure a whole-person approach is taken in identifying gaps in treatment or gaps in available and needed services. Implements Care Plan services and development of health action plan. Offers services where the Enhanced Care Management (ECM) member lives, seeks care or finds most easily accessible. Connects ECM members to other social services and support they may need. Advocates on behalf of members with health care professionals. Uses motivational interviewing, trauma-informed care, and harm-reduction practices. Works with hospital staff on discharge plans as needed. Conducts outreach to and engages eligible HHP members to encourage enrollment in the program. Accompanies ECM members to office visits, as needed. Monitors treatment adherence including medication. Provides health promotion and self-management health coaching.Arrange transportation with ECM members when needed.

Under the supervision of a licensed clinician, I assess patient needs by analyzing patients' behaviors and identifying thought patterns. I speak with clients to help them feel relaxed and open up about their challenges, I provide counseling: by performing supervised individual and group counseling, crisis intervention, and consultation. I help develop treatment plans by creating individualized plans based on patient needs and circumstances. I implement interventions appropriate to the client's presenting problem. I review outcomes of scales and psychological testing, revisiting and revising strategies as needed. I record notes and submit them to EMHR systems.

Use the personal lived experience of a mental health consumer to engage with the participant. Serve as a role model and self-disclose lived experience background to participants as appropriate, to establish trust and demonstrate the possibility of recovery. Provide information and assist participants with access to community services and resources. Communicate with physicians, psychiatrists, and therapists as well as other service providers as needed. Assist with crisis intervention, targeted case management, advocacy, service navigation, and other support. Provide ongoing follow-up contact to ensure participants are connected to appropriate supports and provide additional assistance when needed. Help ensure that services are sensitive to the cultural context and personal history of each participant and their support system; provide services in community-based settings. Ensure that participants and family members are involved to the greatest extent possible in decisions affecting services and treatment. Promote collaboration among support systems, mental health providers, healthcare providers, justice system personnel, school personnel, and other agencies.