Effective care coordination depends on trust and persistence while also requiring a great deal of creative problem-solving. I build strong relationships with clients and their families and gain perspective on how aspects of their lifestyle and health interact. For example, many of the people I serve lack personal transportation or cannot drive because of medical or legal complications. For clients trying to work, secure food for their families, and attend therapy and psychiatry appointments, this poses an enormous challenge. When patients miss a medical appointment and run out of their medication, they risk relapsing and ending up back the hospital. Part of my responsibility is to connect clients with resources in the community like Nassau public transit, the Council on Aging, Barnabas Health Services (also an NHC Host Site!), local food pantries, and sites that offer crisis services. Familiarizing myself with the Nassau community—and building relationships with the people leading these non-profit agencies—has allowed me to devise solutions for patients who need care that goes far beyond the one-time treatment they receive in the ED.
Even tasks as simple as engaging clients in a behavioral health program prove extremely challenging. I will meet with a client one day, and they will tell me how motivated they are to quit using alcohol or another substance. We will make all the necessary plans for them to enroll in a Starting Point program, and I will end the day feeling hopeful, only to hear from the client the following day that they had a bad night, are feeling more despondent than ever, and won’t be coming in to services this week. I have learned not to let setbacks discourage me. Making a life change—especially one as major as enrolling in behavioral healthcare—may require multiple attempts.
I do not heroically solve clients’ problems in a single visit, but I am motivated by the small successes and feedback that I receive with each interaction. One client told me how much he appreciated my ability to listen thoroughly to his story without responding judgmentally, and this helped me to realize the value of care coordination. A doctor in the hospital—having only a few minutes to assess a patient-- might see just an alcoholic or a drug user, while the care coordinator—who serves both in the medical setting and in the community—has the time and opportunity to see more: a father battling depression, for example, who struggles to support his family and uses alcohol to make it through each day. Part of the stigma around mental illness comes from lack of knowledge, but much of it comes from our failure or inability to take the time to understand individuals without making quick judgments. So now, as I help people make huge and difficult life changes for the new year, I am making a New Year’s resolution of my own: to listen to others and to empathize with the challenges they face.
This blog post was written by NHC FL AmeriCorps member, Anna Dowling.
Anna serves at Starting Point Behavioral Healthcare as a Care Coordinator.