Marion Byrd

• Helps with assessing member needs and develops or contributes to the development of care plans/service plans for members with care team in accordance with their goals and preferences for various services (e.g., employment, housing, independent living, justice, foster care, and/or community transitions) including the identification and coordination of referral for care/services
• Assists with connecting members to local resources for various services (e.g., employment, housing, independent living, justice, foster care), obtaining required documentation and supporting the application process, as needed
• Acts as an available resource for members seeking local resource services support and works with members to determine eligibility and care needs based on assessments and care plans/service plans
• Monitors delivery of care/services and performs follow up to members, caregivers, and/or providers to verify members have been transitioned or have access to the appropriate care/service in a timely manner
• Works with providers, community-based organizations, community stakeholders, and governmental entities to support members and their families and/or caregivers in accessing essential care/services and resources in the local community.

• Helps with assessing member needs and develops or contributes to the development of care plans/service plans for members with care team in accordance with their goals and preferences for various services (e.g., employment, housing, independent living, justice, foster care, and/or community transitions) including the identification and coordination of referral for care/services
• Assists with connecting members to local resources for various services (e.g., employment, housing, independent living, justice, foster care), obtaining required documentation and supporting the application process, as needed
• Acts as an available resource for members seeking local resource services support and works with members to determine eligibility and care needs based on assessments and care plans/service plans
• Monitors delivery of care/services and performs follow up to members, caregivers, and/or providers to verify members have been transitioned or have access to the appropriate care/service in a timely manner
• Works with providers, community-based organizations, community stakeholders, and governmental entities to support members and their families and/or caregivers in accessing essential care/services and resources in the local community.

• Providing case management for homeless veterans and maintain case files.

• Assisting veterans with establishing, maintaining housing and assisting with transportation.

• Assisting veterans with increasing income by means of employment or establishing social security benefits.

• Facilitated client assessments to identify needs and develop personalized care plans.
• Monitored client progress through regular follow-ups and adjusted care strategies as necessary.
• Maintained accurate documentation to comply with regulatory requirements and organizational standards.

• Collaborating with other community organizations for continuation of care for veterans.

• Completing intake assessments to establish needs

• Collaborated with interdisciplinary teams to assess patient needs and tailor care interventions effectively.
• Develop partnerships with the array of system representatives, the courts, behavioral health providers, to facilitate transition and re-engagement to the community.
• Collect data for outcomes for individuals served.
• Educate system partners on the role of Care Coordination and continuity of care for those individuals who meet the enrollment criteria.
• Assist providers in developing creative and far-reaching case management / treatment /and/or care coordination plans for these individuals.
• Develop and maintain a list of key agencies and stakeholders and points of contact involved in care coordination.

• Advocated for clients' rights and access to community resources and services.
• Developed comprehensive treatment plans tailored to client needs and goals.
• Collaborated with multidisciplinary teams to ensure holistic patient care and support.
• Updated client documentation for accurate, compliant and current records.
• Interviewed clients, families, or groups to assess situations, limitations and issues and implement services to address needs.
• Collaborated with multidisciplinary teams to ensure appropriate care coordination and resource allocation for clients.
• Educated families on available community resources, connecting them with essential services such as housing assistance, financial aid, or healthcare providers.
• Supported clients and families with empathy and compassion during difficult times.
• De-escalated stressful situations through individual and family crisis interventions.