Outreach Case Manager - PSH

Job Description

Job Description

JOB SUMMARY:

The Outreach Case Manager works with chronically homeless families who are unengaged or disengaged from services. The Outreach Case Manager develops and maintains a caseload of these clients as they are located and re-engaged, providing recovery-oriented case management that integrates evidence-based practices effective with a chronically homeless population, including Housing First, Motivational Interviewing, Harm Reduction, Assertive Engagement, Recovery-Oriented Mental Health Services, Crisis Intervention, and Trauma-Informed Care. Through proactive, field-based outreach and close coordination with shelters, hospitals, jails/detention centers, and treatment facilities, the Outreach Case Manager locates and rebuilds trust with clients, supports them through housing stabilization, and transitions them back to standard case management with continuity of care.

ESSENTIAL FUNCTIONS:

• Identify, develop, and maintain a working caseload of clients who are unengaged or disengaged from services, including those affected by lack of phone/communication access, incarceration, hospitalization, SUD treatment admission, or other barriers to contact, and build the caseload as clients are located and re-engaged.
• Conduct proactive, field-based outreach — including street- and community-based searches, home visits, visits to known locations in the community, and coordination with shelters, hospitals, jails/detention centers, and treatment facilities — to locate, engage, and re-engage disconnected, hard-to-reach clients.
• Develop and maintain relationships with community partners (correctional facilities, SUD treatment providers, hospitals, shelters, and other service systems) to track client status and to facilitate warm hand-offs upon release or discharge.
• Perform initial comprehensive assessments and re-engagement assessments to identify barriers to engagement, and develop individualized outreach, re-engagement, and care plans in collaboration with the client and the assigned Case Manager, addressing short-term and long-term goals as well as needs for housing, ongoing case management, mental health services, and coordination of community services.
• Use evidence-based, low-barrier engagement techniques, including Motivational Interviewing, Harm Reduction, Assertive Engagement, and Recovery-Oriented Mental Health Services, to rebuild trust and reduce disengagement.
• Provide case management to re-engaged clients, including crisis intervention, resource connection, and housing stabilization support, until transition to a standard caseload is complete.
• Provide housing navigation services in accordance with regulations, including assisting clients to obtain necessary documents for housing vouchers and finding apartments to lease.
• Provide ongoing case management support to assess progress and ensure plan outcomes are met or changed as needed through the housing navigation phase and continuing through housing stabilization.
• Conduct in-person meetings and the total number of contacts per month according to regulations, and more often as needed.
• Meet with clients to provide therapeutic supportive case management services addressing mental health, functional, and housing barriers as needed to help clients obtain and maintain housing.
• Coordinate closely with Case Managers to transition successfully re-engaged clients back into standard case management caseloads, ensuring continuity of care and providing intentional supports that move clients from an intensive level of service to a more independent, recovery-focused level of service as appropriate.
• Conduct crisis and risk assessments during outreach contacts, provide appropriate interventions as needed, consult with the supervisor, and complete critical incident reporting within 24 hours in accordance with policies and contract requirements.
• Provide crisis intervention services focused on enhancing clients' ability to independently problem-solve, use effective coping skills, and manage and self-coordinate their own care.
• Participate in regular case conferencing with Case Managers and the Supervisor to review disengaged caseload status and adjust outreach strategies.
• Track and document all outreach attempts (successful and unsuccessful), contacts, and re-engagement outcomes in the electronic health record in accordance with program, funder, regulatory, and HIPAA documentation standards.
• Maintain accurate records of client status (e.g., incarcerated, in treatment, hospitalized, unreachable) to support accurate program reporting and performance outcomes.
• Complete progress notes on every outreach contact or attempt and on every contact with a client or collateral contact, and submit monthly summary reports as assigned. A note is expected after every contact and will be included in the monthly summary.
• Maintain and safeguard confidential client information per HIPAA standards.

ADDITIONAL RESPONSIBILITIES:

• Fully cooperate with the organization's compliance and quality improvement program.
• Participate in staff meetings, treatment team meetings, and trainings, as assigned.
• Represent the program at community outreach events, resource fairs, and provider meetings to build referral relationships and increase program visibility.
• Perform additional related duties as assigned.

SKILLS, ABILITIES & KNOWLEDGE:

• Must possess a high level of tolerance and understanding for individuals and families who present for services with urgent multiple case management and health needs.
• Ability to work independently and within a team environment and exercise mature judgment.
• Ability to provide community and in-home services on a regular basis, including proactive field-based outreach in diverse and sometimes unpredictable environments.
• Strong engagement and rapport-building skills with hard-to-reach or reluctant populations, including working knowledge of Motivational Interviewing, Harm Reduction, and Assertive Engagement.
• Ability to locate clients and track their status through coordination with shelters, hospitals, correctional facilities, SUD treatment providers, and other service systems.
• Strong communication skills.
• Highly motivated self-starter with the ability to manage a caseload and coordinate multiple projects/tasks simultaneously in a high-pressure environment.
• Competency in computer skills, i.e., use of Microsoft Office, Zoom, electronic health record system.

JOB QUALIFICATIONS:

• Bachelor's degree required, degree in a related field preferred and one year of experience providing case management services.
• High school diploma or equivalent plus four years of experience working with vulnerable and marginalized populations, in lieu of the education requirements.
• Experience preferred in the fields of homeless services, case management, mental health, substance use treatment, permanent supportive housing, and community-based outreach in servicing families.
• Flexibility for work schedule to include some evenings and/or weekends as needed for client engagement and outreach.
• Valid driver's license and willingness to drive to multiple sites in Washington, DC for home visits and outreach.

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential job functions.

In the course of performing the job, this position typically spends time sitting, standing, climbing stairs, walking, driving, carrying (20lbs), and lifting (20lbs). Operating a computer keyboard, firm/strong grasping, and repetitive hand control. Able to complete all forms in personal writing. Makes and receives telephone calls. Use of general office equipment, copier, scanner, fax machine. Subjected to outside environmental conditions while conducting field-based outreach and home visits.