Case Management & Care Coordination for Severe Mental Illness

San Francisco Bay Area

Specialized Support for Complex Mental Health Needs

We provide individualized case management and care coordination services for individuals living with serious mental illness throughout the San Francisco Bay Area, including San Francisco, Oakland, Berkeley, Fremont, San Mateo, Palo Alto, and surrounding communities.

Our services are designed for individuals and families navigating complex psychiatric conditions such as:

  • Treatment-resistant depression
  • Bipolar disorder
  • Schizophrenia
  • Schizoaffective disorder
  • PTSD and complex trauma
  • Failure to launch

These conditions often require more oversight and coordination than traditional outpatient therapy. Effective care depends on consistent coordination, advocacy, and long-term support across systems of care.

The Golden Gate Bridge with the San Francisco skyline in the background.

Why Case Management Matters for Severe Mental Illness

Research shows that intensive case management is a beneficial tool for individuals with serious mental illness. In the Bay Area, many public and nonprofit programs emphasize wraparound, community-based support services.

These models demonstrate that individuals with serious mental illness benefit from:

  • Ongoing engagement and outreach
  • Coordination across medical, psychiatric, and social services
  • Support with housing, benefits, and daily functioning
  • Crisis prevention and stabilization

However, access to these programs can be limited an inefficient, and many individuals and families need private, individualized care coordination to bridge gaps in the system.

Our Approach to Care Coordination

We offer personalized, relationship-based case management tailored to each client and their family’s needs.

Assessment

With our comprehensive assessment, we begin with identifying current and future needs, treatment barriers, and system involvement.

Integrated Care Planning

We coordinate across:

  • Psychiatric prescribers and therapists
  • Primary care and specialty medical providers
  • Hospitals
  • Inpatient psychiatric facilities
  • Residential and substance use treatment programs
  • Community and social service agencies

Family Support & Consultation

Families often carry a significant burden when a loved one has SMI. We provide:

  • Psychoeducation
  • Guidance on navigating systems (e.g., conservatorship, CARE Court, disability benefits)
  • Ongoing consultation and support
  • Establishing systems to enhance functioning and to decrease future utilization

Crisis Preventation & Intervention

We help reduce hospitalization recidivism by:

  • Creating proactive crisis plans
  • Coordinating urgent care when needed
  • Supporting transitions after step-downs from inpatient or residential treatment

Who We Serve in San Francisco

Our services are appropriate for individuals who:

  • Have frequent psychiatric hospitalizations or ER visits due to a severe and persistent mental illness (e.g., treatment refractory depression, Bipolar disorder, Schizoaffective Disorder, Schizophrenia, complex PTSD)
  • Struggle with consistent medication regiments or engagement in care
  • Experience functional impairment (independent living, housing instability, unemployment, isolation)
  • Have co-occurring conditions (substance use, medical complexity)
  • Need advocacy within complex systems of care

Many individuals we support would qualify for or benefit from intensive case management models, which are designed specifically for people with significant functional impairments due to mental illness.

Bay Area Communities We Serve

We provide services across the San Francisco Bay Area, including:

  • San Francisco and surrounding areas: Oakland, Berkeley, Orinda, Moraga, Walnut Creek, San Mateo, Burlingame, Menlo Park, Palo Alto, Mountain View, Los Altos, San Jose, San Rafael, Corte Madera, Sausalito, Mill Valley

Services are provided in-home, in the community, and via telehealth, depending on client and family needs.

Bridging Gaps in a Fragmented System

The Bay Area has many strong mental health programs, including community-based organizations offering case management and rehabilitation services for individuals with serious mental illness.

However, these systems can be difficult to navigate. Waitlists, eligibility criteria, staff turnover, and fragmented care often leave individuals and families without consistent and professional support.

Our role is to:

  • Coordinate across systems that don’t naturally communicate
  • Advocate for appropriate levels of care
  • Provide continuity and accountability over time
  • Increasing autonomy and help people live a meaningful life

Private Case Management vs. Public Services

Public programs provide essential care but may have:

  • Eligibility restrictions
  • Limited availability
  • High caseloads
  • Frequent staff turnover
  • Excessive wait times

Private case management offers:

  • Lower caseloads and timely responsiveness
  • Flexibility in services and intensity
  • Collaboration with both private and public providers
  • Consistent, long-term involvement
  • Continuity of care
  • Subject matter expertise

Frequently Asked Questions

Yes! We offer home and community visits, and some of our work is also performed by phone, telehealth, or at the office.

We have an interdisciplinary team that includes social work, recreation therapy, and nursing. We also consult with other disciplines, including psychiatry, peer specialists, therapists, and vocational rehabilitation specialists

We serve San Francisco, the East Bay (Berkeley, Oakland, Orinda, Moraga, Walnut Creek), the peninsula (Burlingame, San Mateo, Menlo Park, Palo Alto), and the North Bay (San Rafael, Corte Madera, Mill Valley). At times, we are able to serve communities in other parts of the Bay Area. Contact us for more details.

We recognize that many people with severe mental illness may also be using substances, and work with them to provide them tools and support to enhance their ability to see how substance use is impacting their life. Our hope is that they are able to curtail their substance use.

We value coordinating care with psychiatric prescribers (including psychiatrists) and other mental health professionals. Our team is well-versed in managing these relationships, and find that connecting with these professionals helps enhance the care and treatment progression of our clients.

It’s natural for people to feel ambivalent about behavior change, and even more so for people who experience severe mental illness. We work to meet our clients where they are at, while also identifying goals that are meaningful to them to help them visualize how they can live the best version of their life.

Families are integral to success. We share meaningful updates, as allowed by our clients and respective privacy regulations. This often includes regular communication, family psychoeducation, and family coaching or family therapy. Likewise, we share community resources, including mental health professionals, advocacy organizations and support groups.

Get Started

If you or a loved one is living with severe mental illness and needs structured, ongoing support, we can help.
We offer consultations to determine fit and develop a plan tailored to your needs.
Contact us today to learn more about case management and care coordination services in the San Francisco Bay Area.

Contact Us