Case Manager Helps Spring Harbor Patients Successfully Transition into Community
Although Liz Center is a Case Manager with Community Counseling Center in Portland, her day typically begins at Spring Harbor Hospital in Westbrook. As a Transitional Case Manager with the Medicaid Emergency Psychiatric Demonstration Project, Liz works with specific patients on transitioning back into the community.
This historic project, funded by the Centers for Medicare and Medicaid Services (CMS), was launched at Spring Harbor in July to address the high use of emergency departments by Medicaid beneficiaries ages 21 – 64 who are in psychiatric crisis. The project has a three-pronged mission: decrease time spent in emergency rooms, reduce lengths of hospital stays, and increase access to community resources and support. Maine is one of only 11 states selected to participate in the project which will provide a combined total of up to $75 million in federal Medicaid matching funds over three years. Spring Harbor expects the project to have an impact on approximately 400 patients per year with an average length of stay of three days.
To carry out this project, Spring Harbor has partnered with both Community Counseling Center and Amistad to bridge connections in the community for the hospital’s eligible patients. While Liz helps link patients to community resources and supports, Amanda Pruett, the Transition Coach/Peer Support worker from Amistad, accompanies patients to provider visits in the community and calls them regularly to offer support and encouragement.
“As part of the patient’s Treatment Team, both of these positions are integral to our ability to provide the best care to patients as they step down from the inpatient setting and into different levels of care,” explained Joyce Cotton, Chief Clinical & Nursing Officer.
In her role, Liz meets with the patients’ Treatment Team soon after admission to Spring Harbor. “I work with patients to develop goals for their treatment journey,” Liz explains. “We consider what has worked before for them and what hasn’t.”
Liz also partners with the patients’ social worker on the discharge plan. Upon her initial meeting with a patient, Liz has a window of approximately 30 days to provide intensive case management services that will help the individual stabilize in the community.
“My clients are typically at their bottom when I meet them,” Liz stated. “I start doing case management right away.” This includes finding the necessary essentials for the patient’s return to the community – food, clothing, and a safe place to live for those who are homeless. Liz may also link patients to other supports in the community such as job counseling.
Since the project started, Liz has worked with 24 patients. “I receive so much gratitude for the work we are doing,” she stated. “A lot of patients say it’s so great to see a familiar face when they leave the hospital. They feel that they are not forgotten.
As one patient recently wrote to Liz: “What you do is extremely helpful and meaningful. I felt like I was not alone and the back-up forces had arrived! This program gave me hope – it made me feel more stable and gave me the step up I needed to keep going.”