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Stories From the Heart of Health Homes

THE JOB OF A HEALTH HOMES CARE MANAGER involves phone calls, appointments, and piles of paperwork, but most importantly, it involves leading with heart. It involves gaining the trust of someone who is suffering and trying to help them through their struggles. These are some of the stories from the hearts of our CCOR Health Homes care managers:



I have a client who struggles with addiction, and I got a notification recently that this client had been in the hospital over the weekend. I immediately looked to see what the Emergency Room visit was for and saw that it was for relapse and suicidal ideation.

I tried to reach out to them via cell phone, but unfortunately, they did not answer. I was worried and had a million thoughts going through my mind, the most prevalent of all being: I hope they are alive and well. I knew that they had a doctor’s appointment that had been scheduled for that morning and called the office. The doctor’s office stated the appointment was a “no call, no show.” Without question, I called their social support who happened to be their father. The father answered and said that he had not seen the client since the Friday before, but he noticed some behavior and attitude changes. He was just as concerned as I was and hoped I would be able to find his child. I then reached out to their mental health provider who said they spoke to the client briefly but was quickly hung up on. Relieved that the client was still alive, I still felt the need to reach them myself. After continuous attempts for a few days following the ER visit, the client finally reached out to me. They had a clear mind at that point and was forever grateful for every phone call that was made and message that I had left for them. It was a rewarding feeling that in a client’s darkest moments, I was able to make a positive impression. My client was beyond thankful for that.



I began working with a client who had been diagnosed with serious mental illness and was raising five children alone. They were homeless, living in a car, sometimes sleeping in the park at night, as the only alternative was to be split up between shelters. As their care manager, I was able to meet with this client and develop a plan to provide the support and advocacy they needed. We met several times to apply for housing, food referrals, clothing closets, and anything else I could refer them to. We were able to secure stable housing and things were going well, and then their eldest son was shot and killed in a drive-by shooting, intended for someone else. I received the call and met with them to see how we could help and try to come up with a support plan. But I mostly just sat with them, doing my best to navigate comforting a parent who had just lost their child, to let them know they were not alone.

We are often asked what we do as care managers, and it is difficult to answer. We are the ones who they often call first in times of need, who are invited into their homes and lives, and who sit with them in the depth of their trauma. We are the ones who rejoice with them in their happiest moments because we know how hard they worked to get there. Our clients go through ups and downs in life, while also at times dealing with extreme mental and physical health issues, substance use, poverty, etc. We, as their care managers, meet them wherever they are and support them however we can within our role.



I began working with a client who is pregnant, has a history of substance abuse, and is homeless. I was looking forward to this case because I am the same age as the client and felt like I could make an impact. We started to work on apartment searching, but I found myself calling her providers to find out if she had a new phone number more than actually speaking to the client. This was definitely frustrating, but I was not going to give up, because I knew she needed the assistance. Unfortunately, I found out from her provider that the client had relapsed on heroin and went to inpatient chemical dependency treatment. After contacting the inpatient chemical dependency agency with no call back, I contacted the client’s mother who shared the client was at the outpatient methadone clinic. The client’s mother provided a phone number, but it was the client’s ex-boyfriend, and he provided another phone number. I attempted to contact the client through call and text and called the client’s mother again with no success. I, then, had to send a disenrollment letter in hopes that the client would reach back out for services. This was not the case, and the client has been discharged from the program due to lack of engagement.

I continue to worry every single day about the client and her unborn child. I think about what I could have done differently and how else I could have gotten the client re-engaged. I think about where she is living and if she is following through with the methadone clinic. It is hard to think about someone the same age as myself going through all of these hardships and there is nothing I can do but be there for support. I cannot force people to do things they do not want to do. This is the nature of being a social worker.



Throughout my career as a care manager, I’ve experienced the full range of human emotion. I’ve been cursed at, hung up on, and worst of all, audited. There are many aspects of this job that are bound to cause frustration, but there’s a reason we keep doing what we do.

Many of the Health Homes clients I’ve worked with felt as though the world had turned its back on them. They often feel socially isolated, distrusting of the medical system, and have backgrounds of trauma and abuse. Being a reliable, genuine, and helpful person to someone who may have never experienced that before is infinitely rewarding. I’ve seen clients in the depths of the human experience rise out of homelessness, poverty, and social isolation. Watching clients discover their own abilities with guidance, oversight, and advocacy has been the driving force behind my desire to work in this field.



I have a client who, in addition to the symptoms of her mental illnesses, has memory issues which can prevent her from recalling recent conversations. Over the past few months I, along with other members of her care team, have received many calls from her expressing anger and confusion, claiming no one was helping her and wanting to stop services. Hearing the client’s aggravation, in addition to the concerns and frustrations her providers have for her can be wearing; it makes me think, “What am I supposed to do? What is my role in this?”

One afternoon, I received a call from this client, who was frantic and sobbing, saying she did not understand who was helping her and what I do for her, adding she was feeling very depressed and anxious about everything. In a calm manner, I explained who her providers are, what each one is addressing, and what my role is in her care. More importantly, I told her we (her providers) are all here for her and are working to ensure she gets the services she needs to better her quality of life. Being told she has support made the client, even if temporarily, feel comforted, cared for, and heard. While we may have similar conversations again in the future, knowing I can have an impact on someone’s day and outlook on their life is very rewarding.

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