Priority referrals are:
- Assisted Outpatient Treatment (AOT)
- 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
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
- Assure the maintenance of case
- Provide services that prevent or
resolve crisis in order to prevent unnecessary use of emergency rooms and
- Provide medication education.
- Assist clients in learning to use
- Provide community support and education.
- Provide wraparound funds for everyday purchases.
CLIENTS NEED TO HAVE ACTIVE MEDICAID TO RECEIVE THESE SERVICES