The Contractor will facilitate data sharing and extraction to identify high utilizers across medical, housing, and criminal justice institutions. Following identification, the contractor will provide case management services for up to 50 Opioid Use Disorder (OUD) high utilizers, convene a collaborative of providers to conduct case conferencing to identify and address barriers to care, and holistically address the needs of clients. All work to be complete within two (2) months of receiving Notice to Proceed after contract is signed. Contractor will perform care coordination necessary to achieve the stabilizing outcome related but not limited to: • Opioid Use Disorder & overdoses; • Homelessness; • Mental Illness; • Criminal legal involvement and reentry; • Complex medical conditions; and • Overdose. Contractor will assign a team consisting of a nurse case manager and a community health worker to each patient. The team will work with the patient until the care coordination outcome is achieved or for up to three months. Hot Spotters care coordination is voluntary, the patient can disengage from services provided by the team at any time. Patients who cannot be contacted for two weeks will be unrolled to make room for cooperative patients awaiting care coordination services.
