What is Care Coordination?
Individuals with severe mental illness and complex care needs often receive support from a range of services and it’s important that the organisations that provide this support communicate and collaborate to provide the best care for the client.
The care coordination model aims to improve care planning and increase the continuity and consistency of care between services. When care coordinators, health providers and other care organisations communicate, gaps and duplication of services are reduced. Care teams provide an opportunity for preventions and interventions to better support the client’s ability to improve their health and wellbeing. Effective care coordination also benefits service providers by preventing burnout to individual workers and services.
A key part of care coordination is providing a wrap-around service model of care for clients and services. Appropriately referring and linking to services, establishing mutual respect and building key stakeholder relationships will ultimately benefit everyone involved.
Care teams provide clients with a strong support network, allowing them to be at the centre of their own treatment and recovery journey. Clients are encouraged to contribute and attend their care team meetings, which provides them with the opportunity to be involved and helps them to understand and navigate the system with the support of services at their side.
Emma has been diagnosed with Bipolar, Borderline Personality Disorder, Post-Traumatic Stress Disorder, Depression and Anxiety and lives in a rental property with her two children. Also having a long history of self – harm; first occurring at the age of 9, Emma has been admitted to hospital a number of times for mental health reasons.
Emma was working part time, however due to mental health issues, substance abuse, housing instability, loss of drivers' license and physical injuries limiting her work capacity, she lost her job and felt unable to move forward.
Due to her mental health issues, Emma was referred to the Mentis Assist Partners in Recovery (PIR) Program. PIR Support Facilitators worked with her to help navigate the system and connect with the services and care she needed. PIR identified her stress triggers including trauma, emotional, financial and medical issues. With the added financial pressure of significant unpaid traffic fines totalling $16,000, Emma felt helpless and that life was not worth living.
With the support of Mentis Assist, Emma worked on her recovery over two years and has regained her sense of hope and purpose. Having been linked with many community supports, Emma has been supported in her journey of self-identity and rediscovery.
Emma has reduced her hospital admissions, has been abstinent for almost one year and is now able to identify her triggers and behaviours and manage her own risk prevention. Linking with community supports, Emma has had her driving license reinstated, had over $16,000 in fines waivered through the courts, reducing her financial burden and risk of homelessness.
With the support of Mentis Assist and linking with community supports, Emma has changed her life and is looking to return to study which will help her return to work.
Emma now feels a sense of hope and purpose; something she says she has not had for many years.