Targeted Case Management Teams

In 2014, MHR's Targeted Case Management (TCM) teams provided person-centered support to 2,295 adults who have been diagnosed with a Serious and Persistent Mental Illness. MHR provides personalized service for individuals in the community who may have co-occurring medical, social and substance abuse challenges.

Our TCM case managers help clients gain access to services needed to meet their mental health needs, achieve recovery, and live independently in the community. Services are provided by skilled mental health practitioners who are supported by a team leader and a clinical supervisor. Case managers work closely with each individual to create a treatment plan, based on assessment of functioning, needs and strengths. We meet with individuals one-four times per month in their home or in the community.

We coordinate services with other providers to help each client achieve personalized goals on their individual treatment plan. Services include:

  • Assessment of functioning and needs
  • Assessment of strengths and support systems
  • Referrals to needed medical, psychiatric, dental vocational/educational, social and benefit services
  • Coordination and ongoing monitoring of services
  • Crisis planning
  • Assistance with finding and keeping housing
  • Access to MHR's health and wellness programming including tobacco reduction, comprehensive dental and InSHAPE
  • Support to solve everyday life problems


Nalda’s Story

Nalda is a 60-year-old woman from Cuba, where she was jailed at 15 years old. “I was brutalized while in jail,” Nalda recalls. “I have not seen my sister or mother since then.” In 1981, she came to the US on the Mariel Boatlift.

Once in the states, Nalda began using drugs to self-medicate from her PTSD and depression, and now lives with Hepitis C and terminal liver disease. She is proud to say that for the last eight years, she has been clean and sober.

Nalda has worked with MHR’s Care Coordination team to find suitable housing and manage her liver disease. She doesn’t let her stage four liver failure stop her. “Nalda has shown tremendous courage and resilience in her recovery,” states Saresse, Nalda’s Case Manager. “She is a great example of how MHR meets clients where they are, and how MHR goes through their journey of recovery with them. We foster hope, and because of MHR Nalda now has more hope than she has ever had.”

Nalda has worked very hard to achieve her social goals and now volunteers at a local homeless shelter and has made a friend. She has a cat and a dog and finds great joy in caring for them. She works out at the gym as a natural way to manage her mental illness, and has recently found her family back in Cuba with the help of MHR Case Manager, Saresse.

“With the help of MHR I have found safe and clean housing that I can afford and it makes me so happy. I just found out that my mother and my sister are alive in Cuba and I feel so happy knowing this. I speak with them now and this gives me so much joy. I volunteer, I take care of my animals and I have my mother and sister back.”