Every client is enrolled in Outreach Services and assigned an Outreach Case Manager (OCM).  The OCM conducts the Intake Assessment with the client, establishes a Health and Assessment Needs Plan and a Plan of Action, conducts clinical screens, completes referrals, and provides general monitoring, follow-up, and support.  The OCM assists clients in advocacy issues, and will accompany the client to medical appointments if the client feels hesitant on his/her own.  For those self-referral clients that are uninsured, the OCM investigates eligibility and assists in applying for health care coverage. For those that don’t have a PCP, the OCM works to find a provider.  The OCM also assists in the delivery of education program components. OCMs provide on-going clinical monitoring via routine and as necessary clinical screens, and home visits for one-on-one education and services for those clients home-bound or otherwise not able to come to classes.  

Outreach Services Include:

  • Health Risk Appraisals
  • Home Visits & Health Assessments
  • Community & Health Resource Referrals
  • Cancer Patient Navigation & Education
  • Providing Linkages to Health Care
  • Blood Pressure screening
  • Glucose, Hemoglobin A1c & Cholesterol screenings  (by licensed staff)
  • Assistance with completing social service applications and forms (ie: DHHS, SSI, etc.)
  • On-going monitoring, follow-up & networking on health and social service encounters with individuals, community agencies and medical providers
  • Schedule appointments and screenings for clients
  • Assist in advocacy issues and will accompany clients to medical appointments

“Clients share that having an Outreach Case Manager is like having an Angel by your side!”

Sandy Kalehua, LPN/ Outreach Case Manager (25 years with HMONO)