SI Behavioral Network, Inc. - Affiliate of ICL

CARE COORDINATION
Priority referrals are:

  • Assisted Outpatient Treatment (AOT) Referrals
  • High users of psychiatric inpatient and CPEP services
  • Jail or prison discharges
  • Individuals who are homeless
  • Individuals with 2 chronic medical conditions

The role of the SIBN Care Coordinator include the following responsibilities:

  • Review of the individual’s clinical history, life goals, service needs, and goals for participation in services.
  • Collaborate with both consumer and provider (s) in the development and implementation of an Individualized Service Plan (ISP) and crisis plan based upon the consumer’s chosen goals.
  • Monitor both the utilization and efficacy of the service package on an ongoing basis and actively work with both the consumer and provider in revising the ISP when indicated.
  • Assure ongoing assessments of client goals, strengths, and skill deficits.
  • Determine resources that will meet the need identified in the assessment process.
  • Coordinate and integrate a written service plan in cooperation with clients.
  • Facilitate service delivery.
  • Coordinate treatment plans with service providers.
  • Assure the maintenance of case management records.
  • Provide services that prevent or resolve crisis in order to prevent unnecessary use of emergency rooms and inpatient services
  • Provide medication education.
  • Assist clients in learning to use fiscal resources.
  • Provide community support and education.
  • Provide wraparound funds for everyday purchases.

CLIENTS NEED TO HAVE ACTIVE MEDICAID TO RECEIVE THESE SERVICES