Kalihi-Palama Health Center

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Ohana Case Manager

at Kalihi-Palama Health Center

Posted: 9/12/2018
Job Status: Full Time
Job Reference #: 884763
Keywords: hospital, patient, health

Job Description

  • 11-Sep-2018 to 10-Nov-2018 (HST)
  • HCHP - Healthcare for the Homeless
  • Honolulu, HI, USA
  • Full Time

Primary Purpose:

Functions as the key linkage between Ohana Project clients and the service systems throughout the community. Responds comprehensively to the needs of clients through outreach, referral, and interim case management. Acts as liaison with QMC and CMC from point of referral to hospital discharge for each client referred to the Ohana House. Assists clients to move into sustainable, permanent housing.  

 Essential Duties:



  • Once a referral is received from QMC or CMC, works with the hospital staff and the patient in assessment of needs and available resources.
  • Makes visits to homeless patients during hospitalization to begin the process of engagement and building a relationship.
  • Maintains communication with QMC and CMC staff during the period of hospitalization to share updates on progress.
  • Assists with the administration process, care plans, discharge planning, and follow-up of homeless patients in coordination with the QMC and CMC staff.



  • Provides interim case management services to all clients admitted to the Ohana House.
  • Provides face-to-face direct service contact for all clients on a daily basis during the time they are residing at the Ohana House.
  • Documents at least 750 face-to-face encounters on an annual basis.
  • Coordinates intake procedures for all clients upon arrival at the Ohana House. Assists in assessment, counseling, and referrals for health/social services.
  • Provides Ohana Project clients with an Individual Recovery Plan (RP) within 72 hours of intake and 30 days thereafter, or as clinically necessary.
  • Meets established goals and metrics for quality and program effectiveness.
  • Assists clients in acquiring emergency supplies, including food, clothing, bedding, medicine and hygiene items.
  • Assists clients with finding, securing, and maintaining permanent housing, and helps clients to reintegrate into the community.
  • Assists clients in applying for entitlements and obtaining identification. Where needed, takes clients through entitlement, medical, and mental health systems to connect them with services and benefits.
  • Assists clients with legal entanglements.
  • Makes appointments for clients and escorts them to such appointments as needed.
  • Provides counseling, consultation, and crisis intervention as needed. Encourages medication adherence as appropriate.
  • Assists with family and social relationships as appropriate.         Where needed, teaches communication and social skills development.
  • Coordinates discharge planning for all clients based on discharge dates established at intake. Works closely with the Ohana Project Coordinator to prepare clients for discharge.
  • Advocates on behalf of clients to ensure equity of treatment.
  • Actively participates with Coordinated Entry case conferencing and QMC High Utilizer meetings as necessary, and other ad hoc meetings as required.
  • Keeps records of all client cases, and is responsible for ensuring that the records are entered into the clinic computer data-base, and for safeguarding clients' confidentiality and other rights.
  • Works with other Project staff in providing a coordinated system of care to the clients.
  • Works as part of a team with other staff for purposes of outreach, back-up, and shared service delivery.
  • Assists other Project staff in obtaining information on clients from other agencies.


Regular and reliable on-site attendance is required. 


Other Duties:

         Performs other related duties as assigned.

  • Observes safety and security procedures; determines appropriate actions beyond guidelines; report potentially unsafe conditions; use equipment and materials properly.


 Minimum Qualification Requirements:



         Good crisis intervention / de-escalation skills.

         Training in substance abuse / dual diagnosis.

         Ability to relate effectively to difficult clients, including mentally ill, chemically dependent, and other homeless individuals.

         Ability to operate a vehicle with valid State of Hawaii driver's license.

         Must provide proof of automobile insurance and clean drivers abstract.

         Ability to work independently in an effective manner.

         Strong communication and interpersonal skills.

         Must be able to work flexible hours to ensure responsibilities are met.

         Ability to work as a team player.



         Bachelor's degree in social work, psychology, counseling, human services or related field.



         One and a half or more years experience providing direct services to homeless persons with substance abuse and/or mental illness required.

         Knowledge of community resources and the Oahu service systems.

         Training in substance abuse / dual diagnosis preferred.


Kalihi-Palama Health Center is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.