The most fragile individuals are typically uninsured/underinsured, homeless and suffering from co-morbid medical and mental health issues, and therefore, tend to be the highest institutional, hospital and emergency department utilizers. Rather than treating them in the hospital emergency rooms or state psychiatric units, these consumers are best served using a community-based model where a collaboration of providers deliver intensive care and support, to collectively and creatively meet the needs of these individuals.
The care coordination will serve to assist individuals who are not yet effectively connected with the services and supports that affect a person’s overall well-being and that help them to transition successfully from needing higher levels of care to effective community-based care.
Coordinated care will link, retain, and support those who may need help taking their medications regularly, getting to their appointments on time, or coping with the psychological and emotional stresses surrounding their diagnosis. Intensive services can offer the right combination of direct and supportive services for each patient to provide stability and offer a safety net so that unexpected events do not have long-lasting negative health consequences.
