Whole Person, Whole Family Navigation
When services are integrated (bundled) to meet the needs of the whole family together, both efficiency and outcomes are made better for the parents, children and families. We work with the family unit to provide opportunities for – and to meet the needs of – the whole person, and the whole family. Our approach and range of programs address the needs of multiple generations within a family and provide for easy access. For example, if a family accesses the agency for health insurance assistance, the universal intake system will automatically assess the family’s need for other supports including childcare and employment and make all available resources available in a “bundle.”
Our highly trained, well-experienced, and compassionate team of Case Managers assess the needs of each individual and then assist them in accessing and participating in the array of services and programs as well as community resources offered through the Community Council and our multiple partners across the county. They continually assess clients for progress not only as they seek help to achieve stability but also as they move towards self-sufficiency and out of poverty. They provide intensive case management services and a complete continuum of care for sustainable results. We integrate services with community partners which are adaptive to individual and family needs, responsive to circumstances and local conditions. We seek to remove barriers and provide tools and supports to engage, equip and empower each client who is below the 125% poverty threshold and shows a desire to change their trajectory. Any one of the Community Council programs can refer clients for this Case Management.
APPLICATION SPECIALISTS & COMMUNITY HEALTH WORKERS
Our experienced Community Services Group not only includes our Case Managers, but also includes Community Health Workers (CHWs) who connect clients to appropriate health services to help families in our communities to get healthy and stay healthy. These same CHWs are also Certified Application Counselors (CACs) and can assist individuals with CHIP, Medicaid or health insurance marketplace enrollment. The CACs follow-up with clients at 45-60 days, at 6 months and 12 months to ensure they stay enrolled in a health plan, have a primary care physician or medical home, and are taking advantage of wellness services and immunizations. If clients or their family members are identified as needing additional support, they too are referred to a Case Manager to ensure they are screened for the Whole Person, Whole Family Navigation program.
The success of our Whole Person, Whole Family Navigation depends relies heavily on our 2-1-1 information and referral services.
These services provide direct links to referral partners and a comprehensive database of community resources such as healthcare, employment, education, legal assistance, housing assistance, substance abuse and more.
Community Council has multiple entry points for clients to access our Whole Person, Whole Family Navigation services and support. Initial contact can occur in a variety of ways including: person-to-person (walk-ins and scheduled visits with our Case Managers), telephone (calling in to our 2-1-1 Information, Referral and Assistance services), electronically (Online application), or via programs (MyRide, DAAA, CYD, CSBG).
In the case of a single emergency need, a Case Manager coordinates a referral and / or provides the service to meet the client’s immediate needs. For clients needing multiple services and extended supports, the Case Manager prescreens them for participation in the Whole Person, Whole Family Navigation program. When referred to a Navigation Coach, who is familiar with the services and supports that Community Council has to offer, the Navigation Coach identifies the needed services with the client, completes the universal intake, works with them to design development plan. Engagement with the client is ongoing as the Navigation Coach coaches the client along their unique pathway. The Whole Person, Whole Family Navigation program requires the clients to commit to the program and work toward case goals that they helped to design based on their specific strengths, resources and needs.
Key milestones for participants in the Whole Person, Whole Family Navigation program vary depending on their own development plan. For example, some may plan to obtain a H.S. Diploma and/or equivalency; while others are interested in obtaining certification and/or a college diploma; whereas for others, obtaining a living wage job and/or middle-income career pathway job may be their milestone. Regardless of their unique plan, we track the clients throughout and for an additional 90 day once their individual milestone is met.