National Care Advisors was recently contacted by a mother for help with her estranged daughter, Jane. Her daughter struggled with untreated mental illness and substance use disorder and had been homeless for several years. Over the years, Jane had multiple encounters with law enforcement for which they would be brought to the hospital for evaluation and treatment. Once medication compliant, her symptoms would reduce, presenting them as “well”. She would then be discharged with no means to continue their medication, establish outpatient mental healthcare and would again decompensate. She was repeatedly failed by poor discharge plans that allowed this cycle to continue for years despite their mother trying to advocate for them.
By the time NCA was engaged in the case, Jane was again in the hospital. Due to a lack of beds in their own county of residence, she was placed in a mental health facility in another county. Despite frequent calls with the hospital social worker, struggles and interactions with law enforcement and conversations with the attending provider, Jane was once again discharged inappropriately on a Friday afternoon. All with no plan on how they would pay for the $3,000 a month medication they were prescribed or transportation to a homeless shelter in another county. She ended up getting out of a cab over 2.5 hours away from where they were living. She had no money and no phone for anyone to contact them to check on their well-being and the shelter they were sent to was closed for new intakes, due to a COVID-19 outbreak. Additionally, had the hospital social worker called to set up intake prior they would have learned that Jane had previously been asked to leave due to past behavior and was not welcome back. NCA reached out to multiple levels of senior management at the hospital as well as the Department of Public Health about concerns related to her unsafe discharge. The client’s mother took to posting on various local social media groups and checking the local homeless encampment to try and find Jane.
Less than a month later, without access to the prescribed medications that had helped them to stabilize in the hospital, Jane was picked up by law enforcement for unsafe behavior and brought into the emergency department for a mental health evaluation. She was again admitted to the same out-of-county mental health hospital. NCA immediately contacted the hospital to advocate for safe and appropriate care for Jane. A new social worker was assigned to the case who reported that nothing that had been provided to the previous social worker had made it into her chart. NCA resubmitted all available records and documentation to the new social worker so that Jane’s care could be based on the long history of repeated behaviors.
NCA maintained ongoing communication with the hospital social worker and local patient advocate about the discharge plan for Jane until the time of her discharge to ensure that the discharge plan was appropriate for her level of care needs.
Jane was accepted at a short-term residential facility closer to home and set up with the county behavioral health coordinator at discharge. Working with Jane, her mom, the staff at the residential facility and the assigned county coordinator, NCA was able to get Jane re-enrolled with MediCal, establish care with a primary care provider, establish care with a mental health clinic, and obtain needed specialist care. NCA referred her to a new enhanced care management through the Medi-Cal program. Eventually, Jane was able to move to a dual-diagnosis residential treatment program to get the care and support she needed to address both her mental health and substance use disorder. NCA continued to advocate for Jane throughout their treatment so that at the time of discharge she was not left homeless. In working with the treatment program and the county behavioral health coordinator to submit applications for housing and board and care options, at discharge from the treatment program Jane was accepted into a board and care within walking distance of her family.
With NCA’s advocacy and support, Jane has been provided the opportunity and resources to take care of her health and regain control of their life. She has been successful in continuing her care and improving her mental health condition. Jane has been able to engage in part-time work and care for herself with support from the board and care staff. Perhaps, the most meaningful outcome is that Jane has been able to re-establish healthy relationships with her mother and their young sons. Her mother has repeatedly thanked NCA as she said she feels that she finally has her child back.
NCA continues to have the honor to work with Jane as she navigates managing her healthcare and public benefits. Currently, NCA is working to coordinate communication between Jane and her professional representative payee as she is not receiving callbacks or answers about their benefit amount and submitted SSI application status.
Do you have a client or loved one who is stuck in a cycle of failure? Contact National Care Advisors to engage the services of our Nurse Case Managers. Located throughout the country, our team is ready to assist today. Contact us at info@nationalcareadvisors.com today.