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Care Coordination Takes an Innovative Approach to Case Management at the Mental Health Association of Westchester

A 62-year-old woman named “Mary” from White Plains, New York has been diagnosed with a serious mental illness. During her lifetime, Mary had experienced a 20-year incarceration and multiple psychiatric hospitalizations. She was referred to The Mental Health Association of Westchester’s (MHA) Care Coordination Program in July 2008 after a long-term state psychiatric hospitalization. When Mary first met with the Care Coordinator, it was explained to her that Care Coordination is an Intensive Case Management and Peer Support program that differs from traditional services by employing a Person-Centered Planning approach in an Integrated System of Care.

Mary wasn’t quite sure what that meant but she heard that someone was willing to help her and she knew that she was going to need a different kind of help than she had in the past. Mary explained to the Care Coordinator that her greatest concern was making sure that she was able to abide by the conditions of her parole so that she never had to spend another day in jail. Mary also stated that her overall goal was to be able to live a healthy and happy life in the community. Right away she and the Care Coordinator started to map out small, easy to reach steps that would allow her to do this. They started to identify people and supports both from her life and from the mental health/criminal justice system that could support her in reaching her goals.

Mary has described Care Coordination as “a blessing in my life.” Within the first few months of discharge, Mary encountered some challenges such as establishing the correct amount of Social Security benefits, finding appropriate transportation to her mandated appointments, and advocating for herself at her Treatment Apartment.  Together, Mary and her Care Coordinator addressed those concerns to a satisfactory end. Mary has found her Care Coordinator to be “supportive, hardworking and honest,” which has been a comfort when various problems arise.

Right now, Mary’s daily schedule consists of going to her treatment program, seeing her parole officer and attending meetings with staff at her Treatment Apartment. With the support of her Care Coordinator, Mary has begun to involve herself in more activities and has expressed an interest in taking up former hobbies such as knitting. Her Care Coordinator is helping her find places in her community where she can knit, meet and socialize with others so that her days are not only spent attending treatment related activities but are filled with the types of activities that will further her personal goals and interests. Mary looks forward to one day being in an apartment of her own, and living a full, productive life in the community.

Mary and her Care Coordinator believe this can and will happen. It has moved from a dream to an attainable goal. The person-centered approach being utilized puts the focus on Mary’s unique needs and treats her as a person with choices to exercise. It preserves Mary’s dignity by inviting her to play a leadership role in a collaborative planning process, and provides her with services and supports based upon her dreams, interests, preferences and strengths. The Care Coordination model differs greatly from previous individualized planning processes that traditionally focused on keeping individuals diagnosed with serious mental Illnesses “stable” by matching them with the services that “the system” was set up to offer. This approach looks beyond assessing an individual’s symptoms and basing outcomes on reducing hospitalizations and increasing medication compliance, and looks to what the person truly desires as a human being, not restricting them to what the program or service can offer.

The Person-Centered approach creates a team of people who know and care about the individual, who come together to develop and share a dream for the person’s future, and who work together to organize and provide the supports necessary to make that dream a reality. This network might include relatives and friends, recovery mentors, clergy, landlords and service providers. This coordinated network also includes providers from across service systems so that the broadest possible array of resources can be brought into play as needed. This approach is what helped “Lila,” another participant of the Care Coordination program, to secure her own apartment through MHA’s Shelter Plus Care program.

Lila had been saying for some time that she wanted to live on her own, but her treatment team opposed this and would not recommend her for independent living. The treatment team was worried that Lila, who had been recently released from jail and had experienced an extremely traumatic event, was ill prepared to live on her own and they worried about her safety. Lila and her Care Coordinator planned for the next treatment team meeting and Lila was able to articulate how she would care for herself. She answered her treatment team’s concerns and discussed the supports that she and the Care Coordinator were putting into place so that she could accomplish this goal. It took some persuading, but the team finally agreed to support Lila’s dream. Lila has now lived independently for 8 months; she is completing a substance abuse treatment program, preparing for a GED program and looking forward to starting computer classes. Lila credits her team for believing in her—even before she did—as the main reason she has been so successful.

A unique aspect of the Care Coordination program is that there are funds available called Self-Determination dollars that can be accessed by participants to further their stated goals. Some common uses for Self-Determination dollars are to pay for alternative therapies not covered by insurance, college courses, community workshops, tutors or clothing to wear on an interview or for a job. “Thomas,” a 21-year-old participant of Care Coordination was able to utilize these specialized funds to deal with an ongoing and troubling issue that had prevented him from taking public transportation. Thomas, who was very motivated to get his GED, admitted to his Care Coordinator that his biggest barrier to accomplishing this goal was his anxiety while he rode the bus to and from school. After discussing various ways that he might reduce his anxiety, it was discovered that listening to music distracted him enough so that he could not only get on the bus but also stay on it until he got to school. It was decided that he would use self-determination funds to purchase an iPod that he uses daily so that he can regularly attend school.

The Care Coordination program is targeted to serve adults diagnosed with Serious Mental Illness with a high need for clinical and support services. A typical candidate for the Care Coordination approach would be a person with some combination of the following circumstances:

  • frequent crises;
  • a history of repeated hospitalization or incarceration;
  • absence of a constructive social or family network;
  • unstable housing;
  • a lack of daily structure;
  • difficulties engaging in treatment, taking prescribed medications or self-monitoring; and/or
  • those who have been in-patient for lengthy periods in state hospitals.

Care Coordination may prove to be a viable solution when traditional systems of support have proven inadequate to achieve treatment and rehabilitation goals. For instance, in places where the approach has already been tried, mental health professionals have been pleased to discover that the participants who had in the past been viewed as “non-compliant” became much more motivated to work toward their recovery, once they were offered opportunities to exercise more control over their treatment plan and make informed decisions.

Eligible enrollees work with either a MHA or Westchester Department of Community Mental Health (DCMH) Care Coordinator and a Recovery Mentor from the Empowerment Center in New Rochelle, NY, thus ensuring access to Intensive Case Management and Peer Support services that address the individual’s specific needs, as defined by the individual. Care Coordinators and Mentors operate as a team with 24-hour access serving a total of 48 participants and delivering a minimum of 4 face-to-face visits per month per participant and making the following services available:

  • Work with enrollees to develop individualized Wellness Recovery Action Plans.
  • Work with providers to arrange admission into desired or needed services.
  • Coordinate mental health, chemical dependence, medical, legal, housing and needed support services.
  • Provide guidance and access to self-determination and service dollars.
  • Provide ongoing case management services.
  • Assess the appropriateness of treatment/services and review plans every 6 months.

Although the principles and values of Person-Centered Planning are not new, the adult mental health service system remains fragmented. Adults diagnosed with serious mental illnesses still have high unemployment rates and are faced with a lack of affordable and appropriate housing options. Too many individuals with serious mental illnesses still reside in shelters or adult homes that are not environments with a recovery-based culture. MHA believes that the Care Coordination project can initiate system change because the model has been effective when implemented. The well-established Western Care Coordination Project (WCCP) has reported for its participants a 59% reduction in emergency visits, a 62% decrease in days in hospital, and a 44% increase in gainful activities such as school, volunteering, or employment. MHA and its partners, DCMH and The Empowerment Center, are extremely optimistic that the Westchester County Care Coordination program will yield positive outcomes for people participating in the program. Additionally, MHA has found that this innovative program has led to a transformation of philosophy and practice throughout the agency so that services are recovery-oriented and person-centered.

For more information about Care Coordination or MHA’s Recovery Oriented Rehabilitation and Treatment Programs, please contact Ruthanne Abramovich, Assistant Executive Director, at 914-345-5900 x299 or visit our website at

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