Helping the Most Vulnerable Among Vulnerable Populations

Our client, LM felt guilty when she wasn’t able to make it to her weekly counseling session. She felt like the therapist she was working with became disappointed with her and that added guilt made her not motivated to go to the next counseling session as well. The therapist wasn’t necessarily imposing this disappointment and guilt on LM, but LM’s perception colored her view of her relationship with her therapist, thus putting her path to recovery in jeopardy.

HCBS (Home and Community Based Services) helps diffuse such situations. The HCBS counselor went to LM, rather than requiring her to come to them. With a person speaking to her where she was most comfortable, LM was able to express her reluctance about leaving her home and together, the HCBS counselor and LM were able to come up with a plan of action that enabled LM to slowly become more comfortable and empowered to go outside her apartment and eventually be able to walk to her therapist’s office.

Because of ICL’s HCBS services and the manner in which we’ve educated Managed Care Organizations and Health Homes on what HCBS can provide, our outreach to the individuals who utilize more insurance dollars than anyone else has helped interrupt the revolving door of people repeatedly entering and leaving hospitals for the same reason. Agencies such as ICL serve the most vulnerable populations, people living in extreme poverty who exhibit both mental health and physical issues—sometimes more than one of each. HCBS focuses its attentions on a population within that group—those who on average, incur more Medicaid spending (it can near $36,000 per person per year) in hospitalizations and emergency room visits.

HCBS staff works on the triggers that can set that revolving door into motion. They connect with the people they serve and work with them to identify what causes them to experience an increase in symptoms. With extra support that is provided wherever the individual feels most comfortable, attendance in outpatient programs has improved and rapport with treatment providers has been re-established.

Another client is JD, who needed to reconnect with her therapist and find a way to speak about the barriers to open communication. She was frightened and afraid that she was going to fall back into her substance use habits. When she reached out, the therapist wasn’t able to connect with her on the level she needed. JD felt that she was being placated and wasn’t making the connection she needed. She was ready to step away from her treatment, but instead she reached out to HCBS. Staff worked with both JD and her therapist and provided an intermediary who was able to convey the concerns to JD’s therapists. Their relationship improved, so much so that JD was able to start sharing positive experiences as well as talk about her challenges. HCBS services aim to be holistic, looking at each individual from all aspects of the person’s life. ICL makes sure individuals utilizing HCBS services have all the appropriate care lined up in their corner—from case manager and peer counselor to social worker and psychiatrist. Everyone is focused on supporting them on their road to recovery and living a successful life.

HCBS does more than offer counseling. Staff looks beyond behavioral health issues and focuses on what steps are needed for someone to become an active member within their chosen community, how to reconnect with family and friends, and ways to move ahead in life. Staff talks about employment service, education opportunities, wellness and healthy living, medication management, socialization skills, self-care, and much more.

HCBS services are flexible, changing according to an individual’s needs. Services address each person’s anxieties, mental health issues, physical complaints, and more. The care given is person-centered and goal-oriented, and each goal achieved is celebrated. Since ICL started its HCBS services, enrolled consumers have been receptive, motivated to improve their quality of life as well as self-determined and self-directed. Staff has helped mend strained family relations—so much so that family members have been able to step up to help someone avoid a hospital admission. Clients report better medication management and adherence and treaters report more attendance at regularly scheduled sessions.

By focusing on the most vulnerable within an already overwhelmed population, HCBS has started to slow the revolving door of readmissions into ERs and hospitals and turn the tide of overspending Medicaid dollars.

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