Care Coordination Program

Working Together To Improve Mental Health Care In A Crisis

People experiencing a mental health or substance abuse crisis often end up in an Emergency Department (ED). There, they are typically stabilized and either hospitalized for further treatment, or released with referrals for follow-up care. But, in general, the system is poorly coordinated and fragmented, often resulting in lack of follow-up care, higher healthcare costs, inadequate services, reduced satisfaction for both clients and the care providers, and lower life expectancies.

These issues prompted an innovative collaboration between Starting Point Behavioral Healthcare and Baptist Medical Center Nassau. Working together for more than six months, the two healthcare providers created the Care Coordination program, which identifies individuals who need additional care when they come to the Baptist Medical Center Nassau ED. With a mental health counselor from Starting Point working in the ED, patients with serious mental health or substance use issues can be quickly assessed and referred to a coordinated program of care that addresses their physical and mental health needs.

image of the front of baptist medical center nassauThe goals of the program include not only improved care and outcomes for the clients, but also a reduction in the number of return visits to the ED. When the individual is part of an ongoing system of care, fewer return visits to the ED are needed.

Renda Cardenas is the Starting Point Care Coordinator in the ED. Working with Samantha Webb, a Certified Peer Recovery Specialist for Starting Point, and the physicians and nurses of the ED, Cardenas has a unique opportunity to touch lives.

“I am an advocate for the patient,” she said, “I look for how I  can connect with them so their lives can be empowered and stabilized. The biggest thing is to be able to establish a rapport and true.

“After discharge, we follow up daily for 30 days,” Cardenas said. “There is a home visit within the first seven days.” Throughout the first month, contact is made by phone, text or additional visits. If clients need additional services, such as housing or food, they can make those referrals as well. 

Webb, a former client of Starting Point, today uses her life experience to help others in the Care Coordination Program. “I help facilitate the treatment plan,” she said. “I can take someone to the doctor, pick them up, etc., and help them find the resources they need in our county.” She also makes home visits and contacts clients by phone or text. “Even after 30 days, I call to remind them about their appointments,” she says.

Laureen Pagel, CEO at Starting Point, said the team began planning in January and met weekly  to determine how to implement the program. The group worked on merging the services in with the work flow of the ED. 

“We were taking a care coordination model that exists on the medical side and applying it to behavioral health,” Pagel said. “The program is primarily for high need, high risk individuals with mental health or substance abuse disorders.”photo of young man and older man talking

“I was very conscientious about working around (the physicians and nurses) and with them,” Cardenas said, noting that part of her preparation included going through the Baptist training and orientation processes.

Kellene Sauls is the Nurse Executive at Baptist Medical Center Nassau and was part of the Partnership Team that developed the program. Sauls says the program has resulted in improved patient care now that there are more resources available to them.

“Before, we were making the handoff (to a mental health provider) with a card,” Sauls said. “Now, it is a warm hand-off with Starting Point. There is face-to-face interaction that helps them to connect and stay connected.”

Sauls said the team studied data from both organizations for about a year to determine what the needs were. She said the results were “totally opposite” what they expected. “There was the expectation that (the need) would be for nights and weekends, but the data showed it is Monday through Friday from 8:30 a.m. until 1 p.m.”

The program is among the first in the state of Florida to feature a collaboration between the ED and a Behavioral Health Provider. A grant from the Baptist Foundation provided funding for the program to get off the ground.

“We want to make sure every patient at every point is touched every time,” Sauls said, adding that by collaborating with Starting Point, it allowed Baptist to expand its program. “We don’t have the resources to follow up with every patient who comes through the door of the ED.”

Pagel agreed, adding “we follow up even if the client doesn’t initially take part in the program. We don’t like to take “no” for an answer. We are very successful.”