Care Coordination is the systematic management of the System of Care to ensure that individuals with the highest level of need are being linked to community-based care and provided the appropriate supports to ensure that their treatment needs are properly addressed. These needs may include, but are not limited to, housing, community supports, linkages to community treatment providers, follow up between treatment providers to safeguard a smooth transition between levels of care and any additional assistance the consumer may need in order to be properly integrated into the community.
The long term goal of Care Coordination is to be able to utilize the data collected through this process to develop behavioral health treatment protocols similar to those that are currently used in the medical field. The development of these protocols will enable the system to better identify crisis indicators and improve early intervention services.
Pursuant to s. 394.9082(3) (c), F.S., the Department of Children and Families (Department) has defined several priority populations to potentially benefit from Care Coordination. Managing Entities and Network Service Providers are expected to minimally serve the following two populations:
- Adults with a serious mental illness (SMI), substance use disorder (SUD), or co-occurring disorders who demonstrate high utilization of acute care services, including crisis stabilization, inpatient, and inpatient detoxification services. For the purposes of this document, high utilization is defined as:
- Adults with three (3) or more acute care admissions within 180 days; or
- Adults with acute care admissions that last 16 days or longer.
- Adults with a SMI awaiting placement in a state mental health treatment facility (SMHTF) or awaiting discharge from a SMHTF back to the community.
Populations identified to potentially benefit from Care Coordination that may be served in addition to the two required groups include:
- Persons with a SMI, SUD, or co-occurring disorders who have a history of multiple arrests, involuntary placements, or violations of parole leading to institutionalization or incarceration.
- Caretakers and parents with a SMI, SUD, or co-occurring disorders involved with child welfare.
- Individuals identified by the Department, SFBHN, or network providers as potentially high risk due to concerns that warrant Care Coordination, as approved Network Service Providers by the Department.
Care Coordination Department Manager
Yisel Morell, M.S.
Lead Care Coordination Specialist