Population Health Innovation Lab, a Providing Access and Transforming Health (PATH) Collaborative Planning and Implementation (CPI) Facilitator, shares the following story reported by one of their collaborative participants, Community Supports Network (CSN).
CSN’s mission is to help people with behavioral health challenges realize their potential by providing hope, wellness, and high-quality supportive housing.
A CSN client encountered a pivotal moment in their life when their leg had to be amputated due to an infection stemming from knee surgery. Despite enduring two unsuccessful attempts at obtaining a prosthetic leg, they found themselves confined to a wheelchair. Over time, the emotional toll of limited mobility led to a diminishing sense of hope.
Recognizing their struggles, the client’s daughter-in-law offered support. She facilitated a referral to CSN, recognizing that her parent-in-law qualified for Enhanced Care Management (ECM).
The CSN care management team addressed the client’s physical health and emotional well-being. Using motivational interviewing, the case managers delved into the sources of trauma, crafting
personalized care plans and goals. Through close collaboration with doctors, Medi-Cal managed care plans, and the case management team, the client successfully acquired a prosthetic leg that truly fit. This achievement marked a turning point, opening the door to renewed hope, mobility, and a revived sense of purpose.
Initially, when engaging with this patient, some case managers suspected a substance use disorder due to observable behaviors, such as nodding off and missed appointments. However, a deeper investigation revealed the client’s actions were rooted in the intense pain resulting from a knee infection, subsequent amputation, ongoing pain management challenges, and reduced quality of life. Doctors initially perceived them as merely seeking pain medicine.
ECM, coupled with motivational interviewing, played a crucial role in uncovering biases within the medical system. Through the implementation of ECM, CSN assembled a specialized team to more effectively engage with the client and advocate on their behalf, dismantling barriers that hindered progress.
Obtaining approval for a prosthetic leg, especially after two previous misfitting attempts, required overcoming significant hurdles. However, with the support of the dedicated care team and the advocacy facilitated by ECM, the necessary approvals were secured. This accomplishment marked a triumph over administrative challenges and, more importantly, exemplified the transformative impact of comprehensive care in restoring the client’s mobility and overall well-being. Sharing this story emphasizes the nuanced nature of complex care and highlights the indispensable role of ECM’s collaborative, patient-centered approaches in achieving positive outcomes.
Have you joined your local network of CalAIM stakeholders working together to implement quality Enhanced Care Management (ECM) and Community Supports services for members?