Table 3.
Quotes and Themes Across the Coordination Levels
| Coordination level | Themes | Quotes |
|---|---|---|
| Provider-level | Bridging across services | “So there are clients that I actually arrange all their doctors’ appointments and actually bring them to them and sit with them during the appointment time” (case manager, community mental health center). “We have somebody that’s doing cancer treatments; that’s numerous times per week. We have one person right now who’s on dialysis three times a week, which takes a lot of time and coordination” (case manager, community mental health center). “The combination of severe mental and physical illnesses—that was really difficult to manage. So I actually had his case manager from the county mental health agency, who was his, quote, lead care coordinator, I had him come to every single office visit and work with my social worker to do care coordination” (primary care provider). |
| Managing interprofessional communications | “We have access to the medical hospital system as long as we have the electronic releases signed. We are able to access records and review medical records, which is great when we find out that they just went to the emergency room or they’ve been admitted or they just recently had an office visit, but that doesn’t go both ways” (program director, community mental health center). “It is very poor communication that we have with the mental facilities. We get almost zero records or recommendations. They very seldom will send us back a care plan” (primary care provider). “So our local hospital here has a behavioral health team and found a handful of people receiving behavioral health services there and at the community mental health center. The big hole was that primary care did not know that their patients had a major mental illness and wherein mental health treatment” (division director, community mental center). “Lack of cell services, lack of internet is definitively an issue” (adult service division director, community mental health center). |
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| Contrasting perspectives on the locus of responsibility for coordination | “How does coordination get paid in a way that commiserates with the work that’s happening and the time it that it takes? You can’t have the conversation we need to have, and the coordination of care in 15 or 20 minutes, with someone with a serious mental illness” (therapist, community mental health center). “We probably deal with 30–35 different primary care offices for just our adult population” (division director, community mental health center). “Case managers play an active role in getting individuals hooked up with benefits, housing, transportation, primary care” (division director, mental health center). “We’re not considered case managers, although having said that, sometimes it ends up that I do more active case management because of the needs of the person” (support counselor, social service agency). “The handoff of three people, having somebody come in and help them with their medicines or check their blood pressure at home, the amount of visits and phone calls and portal cases that have no longer been directed to my office, is huge” (primary care provider). |
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| Individual level | Support for self-management and care navigation | “Just with the nature of their illness, they might not be aware of their medical condition or might need help really advocating for themselves to get their medical needs met” (ACT team leader, community mental health center). “I do whatever I can in my role to keep them as independent as possible. Often that is working with them to make sure that they make it to medical appointments” (case manager, community mental health center). “Initiating certain antipsychotics, we’re always having a conversation about the risk of weight gain and glucose intolerance” (primary care provider). “We’re not clinical; we’re trying to give the person the tools they need to be able to maintain whatever it is they need to maintain” (support counselor, social service agency). |
| Trusting and continuous relationships | “So I just think that folks really need ongoing, continuous, safe, caring, compassionate support sometimes over the lifetime” (ACT team leader, community mental health center). “A lot of my clients have no families and live alone or live in the residences, so after working with some of them for years, they’re very much connected with me and there is a lot of responsibility that goes with that” (clinician, community mental health center). “It was really important for me to have the person that he trusted in the room because he did not have any family members that he trusted. The mental health worker that had been going out to see him on an ongoing basis for years he’d had a trusting relationship with, and that was what really worked for him” (primary care provider). |
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| The right to individual choice and autonomy | “Just for one reason or another, they don’t prioritize their health” (case manager, community mental health center). “First of all, getting them to accept care is a challenge” (primary care provider). “Sometimes the challenge is getting the person to accept the service in the first place. Whether it is mental health or just basic needs at home, like needing care at home and getting them to the point where they can accept it” (support counselor, social service agency). “When you walk in the door here, you have to sign a release of information. It is very specific on what you want shared, what you do not want shared. They have the right to tell us, I don’t want you talking to XX” (clinical therapist, community mental health center). |
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| System level | Link with appropriate residential and care provision services | “Housing is expensive; it is hard to find and it is hard to keep the persons with comorbid mental health and medical conditions with SMI in housing situations” (support counselor, social service agency). “People have to rely on themselves, friends, or family members or volunteers for transportation. It is a huge challenge the more remote one lives in an area” (support counselor, social service agency). “We can get a CAT scan with a phone call, within 20, 30, 45 seconds, but to get somebody a bath it takes maybe four or five phone calls. Because our system is geared toward making doctors and hospitals money, it’s not geared toward taking care of the basic needs of patients and people” (primary care provider). “We face a lot of discrimination for folks who have mental illness, schizophrenia in particular, around accessing community care homes. People will just say they have schizophrenia. We don’t take folks” (team leader, community rehabilitation treatment, community mental health center). |
| Funding and recruiting and retaining staff | “The state reimbursement rate is very old. I think it’s from 2006, and that affects salaries and program development” (clinical therapist, community mental health center). “We are facing challenges here in this area now, not having enough direct workforce. There just are not enough workers, especially for the Medicaid-supported program. The person becomes eligible, but there is no one to provide the service” (support counselor, social service agency). “We have 200 clinical openings between the 10 mental health centers in the state. We have 21 here, right now, at this agency, which means we can’t serve as many people and they can’t get as comprehensive services as needed” (chief clinical officer, community mental health center). |
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| Policy enablers and integration solutions | “We developed a community care team in the hospital emergency room that does a lot of follow-up in the community for people that are frequently going to the emergency room. We have some representatives from our agency there. We have people for primary care offices that are there. We have people from other social service agencies in town there” (clinical licensed therapies, community mental health center). “We have a formal memorandum of agreement with the hospital and primary care practices where we have embedded staff in the local hospital. We have a contract with them because we’re providing them a staff person and they’re paid for it” (adult service division director. community mental health center). “Our plan is to develop what we’re going to call an intensive transitions team who work with the people identified in emergency room as high risk in terms of medical and psychiatric and substance misuse and that team will do an assessment. We are calling it huddles with primary care teams so that we can discuss these cases and ensure that there is follow-through on any of the areas that have been identified as problematic for the person” (chief executive officer, community mental health center). |
Note. CAT = computerized axial tomography; ACT = Assertive Community Treatment.