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  • Writer's picturemarabriere

The Re-Formed Community Care

There is a shift going on in the delivery of services for adults (age 19+) in our state, Massachusetts.  In addition to being more clinically focused with evidence-based programs, there is a bona fide “family focus approach and emphasize role of peer support.”

The new model intends to promote (my comments in italics):

  1. Active engagement and assertive outreach to prevent homelessness; since the vast majority of individuals with serious mental illness make up the largest quantity of homeless individuals

  2. Clinical coverage 24/7/365 days a year because symptoms and illness do not have a time schedule nor a predictive reckoning other than cyclic episodes and patterns; these come when they do and it is good to recognize that sickness comes when it comes.

  3. Consistent assessment and treatment planning Keep the focus on what is best at this time and consider what may be needed based on current behaviors or concerns.

  4. Risk assessment, crisis planning and prevention Best laid plans do not always work.  Prevention increases the odds for improved outcomes.  Having a plan and a go to increases everyone’s confidence in managing crises.

  5. Skill building and symptom management, The most essential skill for individuals with serious mental illness.  Their families and loved ones need assistance with this also.  Again, let’s look for improved outcomes, safety, and connection for all.

  6. Behavioral and physical health monitoring and support Collaboration is key and this model depends on it.  Including family and loved ones needs to be emphasized, however, since we know that their loved ones matter to them.

  7. Addiction treatment support;  So many of the seriously ill have co-morbid substance use disorders.  They are part and parcel of the same human system.  One cannot be treated without the other.

  8. Family engagement; WE know how valuable our input it.  All of the research indicates improved outcomes when family is engaged.  It is nice to see this vital component of care added to the re-forming of service delivery.

  9. Peer support and recovery coaching  With the additional training that these like-minded individuals have, they are often in the best position to engage an individual with serious mental illness to move forward on managing their symptoms and embracing recovery.  Like family members, tThey are an important bridge in treatment.

  10. Reduced reliance on emergency departments, hospitals and other institutional levels of care.  With fewer beds, less restricted environments, and humane solutions, seriously mentally ill people can be offered the best opportunities for managing their chronic illnesses with the level of support and educaiton that they, and their loved ones, need.

The video below explains how the reforms were identified and the shift to this model which promises to be more effective than the previous community based model.  Let’s hope so, anyway.


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