The Intensive Case Management Program at the Community Health and Counseling is part of a statewide initiative by the Department of Mental Health and Mental Retardation to provide care to people with severe and prolonged mental illness.

The program targets people with severe and prolonged mental illness who are at risk of psychiatric hospitalization, or rehospitalization, and who are homeless or at risk of becoming homeless.

CHCS is trying to engage clients who might not receive mental health services, beause of their illness, or because they are transient, or their problems are so overwhelming that they do not seek mental health services. One of the main objectives of the program is extensive research. CHCS staff are out in the community in locations where mental health clients might come for other kinds of services. Staffers can be found at the Greater Bangor Area Shelter, the Community Link and Support Program and at the Together Place.

Visits are made to the Bangor Welfare Office and the Penobscot County Jail to identify people who could benefit from mental health services but who traditionally are resistant to getting help. The CHCS staff spends time in these locations to become a famillar face and to build relationships with people so they will come to know the case managers as allies and people who want to help.

Help required is usually with the basic necessities: housing, Social Security, some form of income, and assistance with food and health care.

Mary Ellen Quinn is program manager. There are four full-time case managers: Mark Hedger, Ann Whitcomb, Diane Dunn and Paul Austin; a part-time clinical consultant, Karen Shearer; and a housing coordinator, Kerry Sack. Each case manager has a caseload of 15. Staff members are licensed social workers with bachelor’s degrees in fields related to working with the mentally ill.

Once the client has expressed a desire to be part of the program, a comprehensive needs assessment is done. The goal is to get a global picture of the client: what has or hasn’t worked out in the past; what resources are needed; and what goals they have.

ICM provides referral and linkage to community resources such as vocational, housing, financial, medical and legal services. Negotiating service systems can be confusing and frightening. These individuals benefit from having an advocate who can go with them to these agencies.

CHCS has a system of on-call coverage 24 hours a day so that a case manager can always be contacted. Other agencies, or any community resident, may call regarding a client who needs service.

A typical case shows how the outreach system works. A young man in his early 30s, with a history of chronic schizophrenia and who was known to CHCS many years ago, began to talk with one of the case managers at the shelter. He was resistant, guarded and suspicious. He began to develop a relationship with the ICM manager and told her that he had been on the streets for close to eight years.

He had never applied for SSI, although he was eligible. With the case manager’s help, he now receives those benefits. An ICM staff member has been appointed payee for his check so the client can be helped with the management of his money.

CHCS, in conjunction with the Bureau of Mental Health, is working to develop an evaluation program. The collection of data will document what resource gaps exist within the system; for example, there needs to be more housing available for clients, a crisis stabilization program in the community, and crisis respite beds on a short-term basis.

An interesting aspect of this program is its Advisory Committee. CHCS has organized a group of people from the community which includes mental health clients, family members and professionals. The goal is to have a varied perspective on the program and its services to assure quality care.

For more information, contact Mary Ellen Quinn, manager of the Intensive Case Management Program at Community Health and Counseling Service, telephone 947-0366, ext. 276.