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Running Head: CARE COORDINATION

Care Coordination and Mental Health

Christan Mulder
Western Washington University

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Care Coordination and Mental Health
When patients receive healthcare that is uncoordinated, fragmented or even duplicated it
can be costly and very dangerous. The National Strategy for Quality Improvement has
highlighted care coordination as a priority strategy in the improvement of United States
healthcare. The coordination of care becomes increasingly important and further complex when
caring for patients with chronic mental illnesses (U.S Department of Health and Human
Services, 2014). The availability of mental health services and treatment across the United States
is very slim making all the more reason to ensure that these patients receive organized and
efficient care. In 2008, the Whatcom County Health Department published The Comprehensive
Behavioral Health Plan, outlining the substantial number of hospitalizations that a patient with
mental illness accrues. In a single year, people with mental illnesses visited St. Joseph Medical
Center almost 8,000 times with only 297 people accounting for a quarter of these visits
(WCHD, 2008).
The top three reasons that services are unsuccessful at reaching this vulnerable population
group are described by Drukkar et al.,(2014) as patients refusing help or missing appointments,
multiple providers for various diagnosis, and aggressive behaviors by the patient that
consequently excluded them from services. These patients are indeed vulnerable and have the
potential to slip through the cracks of the healthcare system quite easily without proper
advocating and support. Intensive programs that coordinate care are essential for this population
group. This paper will serve to describe a residential treatment program in Bellingham
Washington that serves to provide excellent mental health care and treatment to patients with
chronic mental illnesses.

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Lake Whatcom Residential and Treatment Center
Lake Whatcom Residential Treatment Center (LWC) is a non-profit organization that
provides a variety of resources to those with chronic mental illness. Resources include
independent housing facilities, an intensive outpatient program (IOP), and the program for
assertive community treatment (PACT). This group of students worked specifically with the
PACT team, which is a multidisciplinary team that consists of, registered nurses, psychiatrist,
chemical dependency specialist, mental health provider, peer specialist and vocational specialist.
They work with patients that have a chronic and severe mental illness, typically those who have
had difficulties participating in other mental health services. All members of the team work
together to provide holistic care for the patient. The PACT team has three main goals: to keep
the patient out of jail, out of the hospital, and in housing. Due to the severity of their illness, this
group of patients have a high need for services that go beyond the medical scope such as
activities of daily of living, grocery shopping, and rides to appointments. They also provide crisis
planning, medication monitoring, and much more (Lake Whatcom Residential & Treatment
Center, n.d.).
Care Coordination Models
The PACT program utilizes different aspects of several care coordination models. The
two models observed being used are the Case Management by Locus of Control and Aging in
Place. In the Case Management by Locus of Control model, a patient receives a comprehensive
and holistic evaluation. Following evaluation, a plan is created in collaboration with the nurse,
primary physician, behavioral counselor, and patient. The nurse manages the care coordination
for the patient and holds daily team meetings that include the family and patient. According to
Krause et al. (2006),

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The goal is for each participant to reach his or her best achievable and maintainable
level of whole-person health and relative independence from the health care system,
while raising self-efficacy, health literacy, sense of personal control (locus of control),
functional capacity, well-being, and life satisfaction and reducing expected recurring
health care costs (p. 110).
The plan of care is constantly changing for clients of the PACT team due to the
complexity and vulnerability of their mental illnesses. The PACT team works very hard to
encourage these clients to reach their highest potential and will continue to support them through
the end. The Aspects of Aging in Place model is also used by the PACT team. This model begins
with development of a comprehensive plan of care. In this model the RN is the primary
coordinator of care and depending on the patients needs, the nurse will meet with the patient
monthly or daily (Lamb, 2009). In comparison with PACT, one of the team members will meet
with the patient 1-2 times a day. In researching care coordination models, our group concluded
that the Assertive Community Treatment is its own model utilized by the PACT team. The
Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services
(SAMHS) administration created an evidenced based practice knowledge information
transformation toolkit that provides information and tools to implement the program. As stated
previously, ACT is a multidisciplinary team that serves patients with a severe and chronic mental
health disorder, their goal is to reduce hospitalizations and provide care in a cost effective way
(Horsefall et al., 2010). A combination of the multidisciplinary team and a variety of
comprehensive care and services makes it easier for the patient to be integrated into the
community, as well as makes care coordination easier for the team.
Literature Review

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LWC does not follow any specific care coordination model, but rather pulls aspects from
multiple recognized models. A literature review was conducted specifically aimed at looking
more in depth at the Case Management by Locus of Control Model and the Aging in Place
Model. The results of this review yielded two scholarly articles supporting the integrated services
that LWC is offering their patients in the PACT program. A study published by Krause et al.
(2006) explains that a small percentage of individuals making up health plans, about 3% to 6%,
create as much as 60% of the overall cost of the health plan. These individuals fall into two
groups; the first being those who experience catastrophic events such as major motor vehicle
accidents, and the second being individuals who have multiple chronic conditions and suffer
from psychological and socioeconomic disadvantages. From reviewing previous literature and
conducting their own study, the authors found that integrating both physical and psychological
care by utilizing a multidisciplinary team approach including a primary nurse, physician, and
behavioral health counselor improved a number of health related behaviors for these high
utilizers. For example, participants in the study reported an improvement in physical health,
perception of health and well-being, increased self-efficacy, improved life satisfaction, and
participation in healthier behaviors. The study results also concluded that using a
multidisciplinary approach that integrated services in a holistic manner, decreased the overall
healthcare cost incurred by the participants (Krause et al., 2006).
The second article reviewed examines the impact of nurse care coordination on utilization
and cost by comparing Aging in Place (AIP) to Home Health Care (HHC) (Popejoy, Stetzer,
Hicks, Rantz, Galambos, Popescu& Marek, 2015). The goal of AIP is to deliver long term care
to older individuals in an effort to keep them in their homes for as long as possible. This care
coordination model utilizes nurse care coordinators and advanced practice registered nurses to

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manage a comprehensive care plan that can include medication management, assistance with
ADLs, coordination of social services, management of medical conditions, and collaborating
with physicians and other professionals. Care coordination in HHC differs in several ways
including a shorter duration of time, a specific focus on resolution of post hospitalization health
problems, and no ARNP on the team. The study conducted to compare the utilization and cost of
the AIP and HHC group showed that AIP is more effective in reducing the cost of care for older
adults. The fact that the AIP group in the study was at a greater disadvantage compared to the
HHC group due to more problems with functional ability, depression, and cognition, affecting
their social environment and access to resources, makes an even more compelling argument for
comprehensive care coordination services (Popejoy et al., 2015).
The PACT team places emphasis on client centered care and will encourage the client to
perform activities of daily living independently whenever possible. As multiple care coordination
models are utilized at LWC, it still appears that most of the PACT team is RN driven. According
to Lamb (2013) nurses are essential to assist patients in developing self-regulation skills and
enable them to manage their chronic diseases. This is especially true within the PACT team. The
RN is responsible for either administering medications or checking that the client has taken their
medications. If a client has been noted not taking medications, then a new plan is developed with
the team and the client. Lamb (2013) also notes that programs that are successful enable all team
members to work effectively together and that each member of the team is able to clearly
identify their role and responsibility. At our visits to LWC we have seen amazing teamwork
among the PACT team. They have daily meetings that provide for a time for all team members to
gather together and discuss plan of care for each and every client.

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Case Study
During this project our group had the opportunity to observe the coordination of care for
multiple different clients working with the PACT team. Many different agencies are involved in
the care of these clients and in effort to understand and keep track of involved organizations and
resources available to the client we created a care map that reflects contacts and health care
services specific to each patient. The case study and care map in the following sections of this
paper will introduce you to a specific PACT team client who has been with the team for over 2
years and receives resources from a variety of agencies.
*For the purpose of this assignment the client described in this case study will be referred to as Sam. To
protect the clients privacy this is purely a fictional name.

Sam is a client receiving services from the PACT team through LWC and qualifies for
treatment based on his diagnosis of chronic paranoid schizophrenia and bipolar disorder. In
addition to Sams mental health illnesses he also has multiple medical conditions such as
diabetes type II, congestive heart failure and severe arthritis. The PACT team provides Sam with
a variety of services including medication administration, vocational counseling and support with
housing. Sam is a very intelligent individual who completed multiple years of college and nearly
graduated with a Masters degree from the University of Washington.
Over the past six months its been noted that Sams mobility and ambulation has been
affected by his arthritis. Sam is already dependent on use of a front wheel walker and has been
experiencing a significant amount of pain. The PACT team members have felt for quite some
time now that Sam would greatly benefit from additional assistance in his activities of daily
living. The client has a history of hoarding valuables and unnecessary items that may possibly be
contributed to a few traumatic experiences from his past. Sam has been encouraged and assisted
on numerous occasions to clean up his apartment that is subsidized by the Lake Whatcom

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Treatment Center. The PACT team recently explained to Sam that his apartment was cluttered
and that there was too much stuff accumulating and creating an unsafe living area. This is not the
first time that Sam has been asked to clean up his apartment. The client has been provided with
numerous resources in cleaning up his apartment and has failed three inspections. Last week the
client received an official eviction notice to vacate his apartment. An intake assessment for an
assisted living home through the Lake Whatcom Treatment Center was conducted on this client
and he was approved to move in, however the client has been making himself unavailable for
follow up meetings with PACT team staff and is facing the risk of being homeless on the street
without housing. Multiple care team members have participated in coordinating care for this
client. The patient has initiated his own support by seeking free lawyer assistance through
Whatcom County Law Advocates. Psychiatrist, mental health professionals and PACT team RN
all assist in coordinating and networking the care being provided for this client.

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Figure 1
Care Map

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The clients on the PACT team are each assigned an intensive case manager that assists in
coordinating and ensuring that the clients needs are being met. The challenges associated with
care coordination become increasingly complex when chronic mental and medical conditions are
combined. Figure 1 illustrates the care map of a complex PACT team client working with LWC.
In the center of the map is the client and the surrounding webs are community resources, support,
financial and legal components to this clients care and healthcare needs.
The information included in this clients care map demonstrates just how many different
resources and agencies are involved in the patients care. The information, advocacy and
leadership section includes numerous local agencies and organizations with whom the client
receives services or assistance through. This is definitely a strength of the clients in his ability to
advocate for himself and is demonstrated in this care map. The representation component of this
clients care map is limited to very few basics as the client doesnt network outside of his
community very much. As previously mentioned, the client is actually in the process of being
evicted from his current housing for failure to follow the treatment center residential apartment
rules in housekeeping. Included in the advocacy section and also in the legal section is the
Whatcom Law advocates as the client sought assistance through this organization on his own to
represent him in appealing his eviction notice. Primary support for the client is through the
PACT team as the patient doesnt have family in the area. Church is included in the community
and support section as this is usually the form of recreation and socialization that the patient
participates in. The patient has medical needs that are not described well through this care map.
Unfortunately the clients mobility and health has been declining over the past 6 months and the
team at LWC feels the client should actually be living in a facility that is able to provide a higher

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level of care. The patient is seen by his PCP at Seamar clinic which is connected through the
health section on the map and also is seen by an ARNP through the treatment center.
Under the support section of the clients care map Whatcom County Medic Response has
been included as the patient has been known to frequently call 911 for low blood sugars. Risks
that may involve this patient being seen in the emergency department include failure to meet the
PACT team and take medications as prescribed including insulin. The client is also at great risk
of suffering from a fall due to unsafe living conditions in a crowded area and suffers from
chronic arthritis and associated pain. At this point in time, this client is particularly vulnerable to
a hospital stay or ED visit due to the fact that he has been provided multiple opportunities to
clean up his apartment and has been provided the assistance to help him complete this task. The
client has opted not to follow his apartment rules and is facing eviction. In discussion with the
PACT RN and client case manager this would land the client on the streets without many
secondary options. This client would likely land in a crisis center or the emergency department
without proper housing as his medical and mental health needs require frequent monitoring and a
safe living area. It is critically that this client finds new housing and is supported in a way that
enables him to keep his housing. The client would benefit from frequent reminders on how and
why his housing is so important to his health.
Care Plan
Problem-Sam has received notice of eviction from his apartment that is subsidized by LWC.
Sam needs support from the PACT team to find new housing that he will be able to maintain and
remain within his new housing setting.

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Smart Goal-The PACT team will assist Sam in identifying organizations that can assist in
finding permanent housing for the client. Sam will be assisted to find a new apartment or living
situation that maintains his sense of independence and will be open to receiving additional
assistance with activities of daily living. The progress with this goal will be tracked by
conducting monthly meetings with Sam. PACT team to work with Sam to identify his needs and
values associated with his housing. When housing is obtained, PACT team will assist Sam in
keeping his housing by identifying previous barriers in keeping housing.

Interventions

Goal to be reviewed monthly with Sam, update goals and review where we are at
in process of finding new housing. Explore the importance of independent living
with Sam.

Regular updates to this plan of care will be made in conjunction with Sam and the
PACT team.

Establish an agreement between PACT team and Sam to put forth effort to be
present to scheduled appointments with team members.

Identification of available resources to assist Sam in finding and keeping his

housing.

Provide assistance for Sam to understand which items are valuable to him and
which could possibly be donated or thrown away.

Continue to utilize chore aid assistance

Work in conjunction with opportunity council to identify resources available to

Sam to keep his housing

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Evaluation

The PACT team and Sam will agree to evaluate the process of this care plan every 3
months. Monthly progress meetings will be conducted with PACT team member in
conjunction with weekly RN check in. When Sam has obtained new housing the PACT team
combined with Sam will identify previous barriers to keeping his housing and determine
which barriers can be remedied. We will know that the plan of care was effective when Sam
has found and kept new housing.

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References

Drukker, M., Laan, W., Dreef, F., Driessen, G., Smeets, H., & Van Os, J. (2014). Can assertive
community treatment remedy patients dropping out of treatment due to fragmented
services? Community Mental Health Journal, 50(4), 454459. doi:10.1007/s10597-0139652-0
Horsfall, J., Cleary, M., & Hunt, GE. (2010). Acute inpatient units in a comprehensive
(integrated) mental health system: A review of the literature. Issues in Mental Health
Nursing, 31(4), 273278. doi:10.3109/01612840903295944
Krause, C., Joyce, S., Curtin, K., Krause, C., Jones, C., Kuhn, M., ... Boan, B. (2006).
The impact of a multidisciplinary, integrated approach on improving the health and
quality of care for individuals dealing with multiple chronic conditions. American Journal
of Orthopsychiatry, 76 (1), 109114. doi: 10.1037/00029432.76.1.109http://www.ahrq.gov/workingforquality/reports/annualreports/nqs2014annlrpt.pdf
Lake Whatcom Residential & Treatment Center. (n.d.) Retrieved from: http://www.lwrtc.org
Lamb, G. (ed). (2013). Care Coordination: The Game Changer - How Nursing is
Revolutionizing Quality Care. Silver Spring, MD: American Nurses Association.
Popejoy, L. L., Stetzer, F., Hicks, L., Rantz, M. J., Galambos, C., Popescu, M & Marek, K. D.
(2015). Comparing Aging in Place to Home Health Care: Impact of Nurse Care
Coordination On Utilization and Costs. Nursing Economic$, 33(6), 306-313
U.S Department of Health and Human Services. (2014). Retreived from:
http://www.ahrq.gov/workingforquality/reports/annualreports/nqs2014annlrpt.pdf

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Whatcom County Health Department. (2008). Whatcom county comprehensive behavioral health
plan. Retrieved from http://www.co.whatcom.wa.us/715/WCHD-Reports.

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Appendix

Executive Summary
Care Coordination at Lake Whatcom Residential and Treatment Center
This Care Coordination project was conducted by a team of Western Washington
University student nurses in conjunction with Lake Whatcom Residential and Treatment Center
(LWC). This group of students worked specifically with the Program for Assertive Community
Treatment (PACT) team members: Todd Borne, RN, and Amy, RN. LWC provides residential
and community based mental health treatment and services to adults with chronic mental
illnesses. The PACT team is designed to meet the needs of the most complex clients in the
community with a holistic and individualized approach. The work of the PACT team is based on
collaboration of a multidisciplinary team. The majority of clients working with the PACT team
require assistance with their medical and mental needs and have not benefited from traditional
mental health treatment programs. The purpose of this project and partnership was to evaluate
and assess the way care is coordinated for the mental health population group within Whatcom
County. This report will provide a description of the services provided by LWC and the PACT
team and how their efforts and collaboration with outside agencies are strengthening the
coordination of care for clients with mental health needs.
Problem Description
When patients receive healthcare that is uncoordinated, fragmented or even duplicated it
can be costly and very dangerous. The National Strategy for Quality Improvement has
highlighted care coordination as a priority strategy in the improvement of United States
healthcare. The coordination of care becomes increasingly important and further complex when
caring for patients with chronic mental illnesses (U.S Department of Health and Human
Services, 2014). Health outcomes for the clients being served by the PACT team rely on
appropriate care coordination measures. This vulnerable population group are often unable to
advocate for their own needs and rely on the assistance of organizations and agencies like LWC
to ensure that chronic medical and mental conditions are being appropriately addressed. Clients
with co-occurring mental illness and multiple chronic medical conditions are at an increased risk
of emergency department visits and hospital readmissions due to the complexity in their care.
The clients that are working with the PACT team are among the most severe mentally ill clients
in Whatcom County. There are approximately 70 clients working with the PACT team and range
from 18-70 years of age. This complex group of patients have multiple medical and mental needs
that require consistent support and case management. A huge component of what the PACT team
does is advocating for the clients and connecting them to essential community resources and
developing community partnerships. Resource include linking the client to a primary healthcare
provider, assisting in finding and keeping an apartment, and ensuring basic needs are met such a
food and clothing. The PACT team has three main goals: to keep the patient out of jail, out of the
hospital, and in housing. These clients have a limited ability of resiliency and with the support of
the PACT team multiple hospital admissions and overnight stays in the Whatcom County Jail
have been avoided.

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Process and Methods

The identified population group has been predetermined based on referrals to the PACT team
and LWC. Some clients involuntary seek treatment with the PACT team and many individuals
are court ordered to collaborate with the PACT team. Multiple clients have been released from
mental institutions such as Western State Hospital and have contingencies based on their release
to participate with the PACT team. The patients that were focused on for the purpose of this
project were identified by the program coordinator as being high utilizers of community
resources and were medically complex. The patients were assigned to this group have extensive
medical and mental histories, multiple medical conditions and many with problems involving
housing situations, police department encounters and polysubstance abuse. Each week our team
would review the goals of this project as a group and also with the PACT team RNs. We had the
opportunity on four different occasions to go out into the community and observe the PACT
team in action. We observed daily meetings, interact with the clients in the community and
observe the process of care coordination. We also visited agencies that support PACT team
clients and conducted informal and formal interviews on agency managers.
Results
Through our observations, we concluded that the PACT is an excellent program for this patient
population. The PACT team is keeping frequent utilizers of health and criminal justice resources
out of the emergency room, avoiding incarceration, and living in the community. Our concern is
the lack of data that is being recorded. We believe that recording data about the interventions,
community collaboration efforts, and their results can produce evidence for showing the benefits
of the program. The evidence can then be presented to other organizations that can help with
future funding. Research supporting the success of this program can also be utilized to create
similar programs for other communities or patient populations. Additional funding can be used to
purchase a new EMR system, increase the number of staff, and take on more patients that
desperately need these services. It is also a way to continue and enhance quality improvement of
the program.
Also in our observations it became apparent that there is interdependency between different
programs and resources for this patient population. The utilizers of these services are often
transitioning from inpatient hospital stays, incarceration, or homelessness. The PACT services
have relationships with community resouces such as the Catholic Community Services, and
compass mental health and communicates patient needs with these services. The PACT team
also works actively with the Incarceration Prevention and Reduction Task Force for successful
reduction of incarceration services. These collaborative community efforts have been successful
and reflects the ability for Whatcom community to accept this patient population and
communicate successfully.
Recommendations
Arrange Practice Experience times to be congruent with the RN schedules so that
Western students can shadow them.
Third quarter practice experience (CQI class and community health class) can be done
with this facility. Students can assist with the data collection process.

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Conclusions
The PACT team does an excellent job in communicating and collaborating as a team, and with
the community. A positive implication in recording community collaboration efforts, and
interventions is eliminating fragmented care and better resource usage. Patients with use of the
PACT services have been successful in progressing through being inpatient at a mental health
facility to living independently and having community involvement. One of the greatest
strengths that this program has is the ability to care for the client holistically. The structure of the
program places the client in the center of the care plan. The PACT team strives to empower each
client to function at his or her optimal level. The team encourages clients to focus on their
individual strengths to live the healthiest, best lives they can. A collaborative, community based
approach allows clients with chronic and severe mental illness to create trusting relationships
with their care team, and flourish in their community.
For our recommendation of recording the PACT services and care coordination interventions
which could have negative implications are in regard to large scale funding. If the PACT services
are allocated a larger percentage of mental health funding due to their data collection, this
funding could be coming from a different program which also provides a necessary service in the
community. In thinking about resource funding and allocation, there needs to be community
collaboration and knowledge of where the highest density of use is. A class reading that is
applicable to this practice experience and our recommendations is Hot Spotters by Atul
Gawande. The article describes a story about two doctors that analyze data from medical
databases to determine who the high healthcare utilizers are. From that information, they created
and coordinated with multidisciplinary teams in order to provide holistic care. The results of this
program was a successful one, it lead to a decrease in hospital admissions which in turn, decrease
the amount spent on healthcare. The program described in the article is similar to that of the
PACT services. Mental health patients are high healthcare utilizers and this program offers them
an opportunity to not only stay out of the hospital but also out of jail and kept in housing. We
had the opportunity to observe many PACT clients who were happily living social, meaningful
lives in a home.
References
Lake Whatcom Residential & Treatment Center. (n.d.) Retrieved from: http://www.lwrtc.org
U.S Department of Health and Human Services. (2014). Retreived from:
http://www.ahrq.gov/workingforquality/reports/annualreports/nqs2014annlrpt.pdf