The In-Home Outreach Team (IHOT) North Program provides outreach and engagement including support and education, screening of needs, transitional case management, referrals to community services and crisis intervention as needed. We offer a wide range of services to assist with needs, supports, or desired services. The IHOT North Program provides support, needs assessment, and assistance in problem-solving for: Initial engagement of services, learning to access the support you need from San Diego County clinics and other community services, changes in living situations, and becoming employed or returning to employment.
Guided by peer and family support staff, individualized goals are created to help participants identify and achieve their hopes and dreams. The length of services is based on our participant’s level of need. The IHOT North team members include men and women of varied ages, ethnicities and racial backgrounds, who are trained peer and family specialists. They share their own lived experiences with IHOT North participants and families.

Position Description:
The Care Coordinator provides intensive case management services to clients who are difficult to engage and may deny the need for mental health services in the In-Home Outreach Team (IHOT) program. The Care Coordinator coordinates care for clients and assists them in accessing services and resources that will help maintain them in the community in the least restrictive environment. In addition, the Care Coordinator acts as a liaison between treatment providers and the client and assists clients with the development of social and community support systems that promote stability and enable clients to function at the highest level possible. The Care Coordinator offers extensive knowledge of community resources and support as a primary means of assisting each client to reach their rehabilitation and recovery goals. The Care Coordinator also assists with the referrals and case management of clients who have been assessed as meeting Laura’s Law criteria for Assisted Outpatient Treatment (AOT). Individuals meeting criteria are provided support with receiving services and/or are petitioned to engage in such services as written under the law. The AOT Care Coordinator works in conjunction with the Assisted Outpatient Treatment (AOT) Lead Clinician to appropriately monitor the IHOT caseload of Laura’s Law candidates. The range of authority is consistent with that of MHS Case Managers.
ESSENTIAL DUTIES AND RESPONSIBILITIES: Gathers information for assessment and diagnosis. Conducts intake interviews and completes comprehensive individual assessments of client’s mental status and level of social functioning. Assists in the evaluation of all referrals to determine whether they meet Laura’s Law criteria, as well as those referrals received from reporting parties who specifically request Laura’s Law intervention. The Laura’s Law mental health assessment/examination is to determine eligibility for individuals to obtain court-ordered Assisted Outpatient Treatment (AOT) from the County-identified AOT provider. Prepares and maintains assessments, client plans, progress notes and other records and documentation. Coordinates proposed treatment placements with providers. Facilitates placement including arranging pre-placement visits and transportation. Transports clients when necessary in own vehicle. If the individual is determined to meet Laura’s Law eligibility criteria at the time of IHOT engagement and has not engaged with available and appropriate mental health services, the AOT Care Coordinator will offer the person voluntary services at the same level of services required under Laura’s Law. If the Laura’s Law eligible individual declines voluntary services in the IHOT program, the AOT Care Coordinator may recommend to the AOT Licensed Clinician that the program file a petition to the BHS Director to obtain a court order authorizing AOT services. Conducts chart and treatment plan reviews to ensure compliance with agency, federal, state and local government standards. Responsible for monitoring client progress throughout short-term treatment. Develops and maintains a caseload as assigned by the Program Manager and AOT Lead Clinician. Serves as part of the on-call, late shift, and weekend team, fulfilling all duties of this program component as scheduled. Provides information about the program to community agencies, clients and families, connected to the mental health services system in order to educate them about the program. Provides counseling support to clients and families and encourages family members and client significant others to participate in client stabilization and counseling services and be able to refer those needing specific services and support. Provides on-call services and crisis intervention, and initiates contact with clients on a monthly basis at a minimum. Refers clients to community health, HIV and TB clinics as necessary. Maintains appropriate documentation on all clients as outlined in the Adult Mental Health Services Documentation and Uniformed Clinical Record Manual, including use of identified electronic health record systems. Maintains contact with assigned treatment providers to continuously appraise client progress. Prepares critical care issues for discussion during weekly staff meetings and monthly supervision. Establishes weekly case presentations for review at staff meetings. This process includes all new admissions, discharges and referrals within the past week. Provides input on an ongoing basis to develop and improve program service and delivery. Intervenes for non-open cases in a crisis situation by referring to mental health services. Informs at-risk populations about the need for and availability of Medi-Cal and non-Medi-Cal mental health programs. Provides telephone, walk-in, or drop-in services for referring persons to Medi-Cal and non-Medi-Cal mental health programs. Assists individuals to access Medi-Cal physical health and mental health services by providing referrals, follow-up, and arranging transportation for mental health care. Displays regular and reliable attendance. Reports to and departs from work on time, as scheduled, and accurately reflects all time on time card. Successfully functions as a team member internal to the program and externally with community partners (i.e., law enforcement and legal system).

Education/Experience Requirements:
ABILITY TO: Provides effective case management services and the ability to successfully work as a member of a treatment team. Work with families to support and educate about clients illness, barriers and needs. Create written documentation that is legible, clear, and concise. Maintain the distinction between therapeutic and social relationships. Maintain positive morale and unit cohesion as evidenced by maintaining a cooperative and flexible attitude toward coworkers, showing adaptability to change, exhibiting effective communication and interpersonal skills, and taking initiative to solve problems. Set priorities and reacts appropriately to emergency situations.

EDUCATION and WORK EXPERIENCE: Master’s degree in a behavioral science and at least two years’ experience providing services to individuals with mental illness; Or Bachelor’s degree in a behavioral science and at least four years’ experience providing services to individuals with mental illness. Experience providing care to acutely mentally ill adults preferred. California BBS registered preferred.

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 this job. Reasonable accommodations may be made to enable individuals with qualified disabilities to perform the essential functions.

Seeing
Hearing
Speaking
Stooping/Bending
Moving around office
Moving between offices/clients
Driving (MUST HAVE CLEAN DRIVING RECORD)
Climbing
Lifting/carrying heavy items
Standing for long periods
Working outside/underground
Using hands/fingers