by A’tasha Christian, LPC, E.d.

Care Coordination

One of our biggest challenges as community mental health providers is care coordination – not because we are inept, but often because we simply do not know where to start.  The ideal vision of Community Mental Health here in the Commonwealth was for the MH provider to serve as the navigator of all services that are being provided to the client.  Then, as providers would begin to step out, the long-term provider (typically the social worker from DSS) would take over.  Managed care and high staff turnover often thwarted that goal, so we are often left with a fragmented system of care.  To provide the most comprehensive services for the client, it is vital that the MH provider serve as the coordinator of all stakeholders.

Examples of common stakeholders are as follows:

-MH provider (K.I.D.S. counselor)

-MCO Care Coordinator



-Probation Officer


-DSS Social Worker (benefits such as Medicaid and EBT)

-Housing case manager

Project BRAVO, which is now entering its second stage, calls for a paradigm shift in community mental health.  It is even expected that the name “Medicaid” will change to reduce stigma associated with low socio-economic status. For the first time, a team approach is the goal.  Treatment teams will be the standard, not the exception, and stakeholders will be expected to communicate with one another for the overall benefit of the client.

So how do we begin that process? Great question – glad you asked. The first step that you will take, as the counselor, is to identify ALL stakeholders.  Do not rely on the initial or comprehensive assessment – not because the clinician is not thorough, but because the client often forgets all their stakeholders.  We can all recall having a client who conveniently forgets that they are on probation until you are aiding them with finding an apartment and they do not qualify.

A rule of thumb:  when reviewing your client’s ISP with them, ask them about professionals who are involved with working towards these goals and objectives.  For example: if you are addressing the medication management goal, obtain contact information for not only the psychiatrist, but all other medical professionals.  If your client says they do not have any providers but they have a reported chronic medical condition (such as diabetes or hypertension, ask them who prescribes their meds).  Remember, some times the way we pose the question can get more information.  For example, instead of “who are your medical providers?”, ask “so I know you said you’re a diabetic – who do you see to prescribe you insulin?” Some of our clients are so used to repeated questioning that they shut down and you’re left with minimal information.

Once you’ve gotten your list of stakeholders, complete the releases of information and then contact them.  Inform them that you are working with the individual and ask about any upcoming appointments.  It is not uncommon for our clients to forget their appointments.  While they cannot be charged a no-show fee, they can be terminated as a client.  Therefore, it is vital that we – as the professional – obtain their appointment dates.

Lastly, do not forget one of the biggest stakeholders – the MCO! As a reminder, we should have monthly contact with the MCO Care Coordinator.  Note: if your client does not have a Care Coordinator, confirm that with the MCO.  However, with the expansion of Project BRAVO, it is anticipated that all Medicaid recipients will have a Care Coordinator.  Remember, you want the MCO to know all the good work you’re doing. Why? Because that’s how your client remains in services and gets the help they need and deserve.