Care Coordination is the organization of care activities between two or more participants including the person served and family (with consent) involved in an individual’s care to facilitate the effective delivery of behavioral health services. It offers the opportunity to share information in a timely manner and ensures that individuals being served are followed as they move through their episodes of care. Many of these individuals cycle through the mental health/substance abuse system, jails, juvenile justice system, emergency rooms, homeless facilities, etc., leading to de-compensation of the person’s mental health and creating immense costs for multiple publicly funded systems.
Care Coordination Short-Term Goals:
- Prioritize an individual’s wellness and community integration.
- Improve transitions from acute and restrictive placements such as the state hospital, receiving facilities, crisis stabilization units, SRTs (Short Term Residential Treatment) or inpatient facilities, and detoxification units.
- Decrease avoidable hospitalizations, inpatient care, incarcerations, and homelessness.
Care Coordination Long-Term Goals:
- Help service providers shift from an acute care model to a recovery-oriented system of care model.
- Help communities provide a wide array of services and supports tailored to meet the diverse needs specific to each individual.
At BBHC, Care Coordination Teams have been developed to focus on the population that are high utilizers of the behavioral health system. These teams are located at three (3) of our contracted providers including Henderson Behavioral Health, Archways, and Banyan Health. Critical Time Intervention (CTI) is the primary evidenced-based practice utilized to effectively transition individuals from higher levels of care. These teams provide an intensive case management that focuses on the individuals’ needs, determine level of care, link with existing and newly identified services and supports. The Care Coordination Teams consist of an intensive case manager, a peer specialist, and a licensed clinician. The case load of each team ranges between 15-20 clients. The teams conduct weekly treatment team meetings and provide assessment/clinical services, intervention/crisis support, case management, and peer support. These services are time-limited, with a heavy concentration on educating and empowering the person/family served, engaging and getting to know the person’s needs and natural supports, and providing a single point of contact until a person is adequately connected to the ongoing care once they complete the three (3) phases of this service over a nine (9) month period. The Care Coordination Teams are available 24/7.
The Care Coordinators at BBHC report to the Director of Operations/ System of Care and provide oversight to the Care Coordination Teams. As other individuals who are high utilizers of the system require assistance, these Care Coordinators facilitate community linkage to insure their individual needs are met.
For additional information, contact Celena King, System of Care Manager at: [email protected]