Case Managers serve as the anchor of each resident’s care team, providing consistent, personalized support that addresses both immediate needs and long-term goals. Upon admission, Case Managers conduct a comprehensive bio-psychosocial assessment that informs a collaborative, person-centered service plan. This plan is not a static document but a living roadmap that evolves over time, reflecting progress, setbacks, and shifting priorities. Through regular in-person meetings, residents and their Case Managers track milestones, reassess needs, and problem-solve together. Case Managers also ensure that residents are connected to benefits and entitlements, including Medicaid, SNAP, and public assistance, which are vital to sustaining both health and housing.
Beyond individual care planning, Case Managers function as system navigators and advocates. Many of our residents have active involvement with multiple systems (e.g., child welfare, healthcare, justice, education) and have unfortunately experienced trauma or discrimination in those settings. Our Case Managers are trained to help residents re-engage with these systems in ways that are empowering and rights-based. In doing so, Case Managers help reduce barriers that often prevent individuals with mental illness from reclaiming stability.
