Case Coordination

The Miami Street Medicine program offers limited, goal-oriented case coordination for our patients. A Case Coordinator comes out on each street run, and during their interview with the patient, they will risk stratify and screen for their medical-social needs.

 

 

Principles

 

Case Coordinators will deliver on the agreements and relationships that are developed on the streets. The Case Coordinator will assess, and then communicate the patient's needs and their information to the attention of the Patient Navigation team who will take on a case file for each client. The Case Coordinator must seek progress updates on each case and communicate that information to the team before the next street run.

 

In addition to the cases which the MSM Case Coordinator picks up, there may be clients referred by our partner organizations (i.e. Camillus Health, Jackson) for our follow up on the street. It is highly recommended to check MSM’s email and request form each day (role of both the Director of Patient Navigation). This will allow other organizations to contact the program at any time to coordinate care of clients. In this case there should be a specific goal in mind by the partner organization (for example, Camillus may just want to know why a client is not showing up at health follow-ups). Immediate in depth case management might not be available for each new client. Some progress should be made to address their immediate needs and establish a plan for further interventions. This requires flexibility and good cooperation.

 

The core components of case management are:

  1. Identify common goals

  2. Develop a service plan

  3. Identify strengths and barriers

  4. Support and motivate the client

  5. Offer resources and direction

  6. Advocate and collaborate with relevant organizations

  7. Monitor and adapt in concert with the client

  8. Celebrate the successes of each client

 

  • Clients who have critical problems such as pregnancy, unstable disease or other vulnerable conditions are prioritized.  

  • Other highly motivated clients who are likely to stabilize with a few basic interventions are streamlined for rapid management.  

 

In depth counseling should be conducted in a quiet, private setting. Helping persons experiencing homelessness will involve both tangible resources, such as housing, and access to affective resources, such as belonging and socially valued roles. Case coordination continues to be client driven and staff facilitated. Safety and confidentiality is essential.

 

Criteria For Care Coordination Intake

 

Patients must meet at least one of criterias (I), (II), or (III), (IV), or (V)

  1. High-Risk Criteria

    1. Positive HIV screening

    2. Positive HepC screening

    3. Youth & YA (18-21)

    4. Pregnancy

    5. New-onset diabetes

    6. Desire to enroll in medication-assisted treatment for substance use disorders

    7. Expresses desire to harm self or others

  2. Patients with acute problems that are likely to stabilize quickly with basic management 

    1. Wound Care (drainage, sutures)

  3. Other as defined by attending physician

    1. Example: continuous, documented, unmanaged hypertension

  4. Requested followup by partnership organization

    1. In this case, patient coordinator, patient navigation volunteer, and patient will meet in person to make introductions and set expectations.

  5. Medical non-acute need

    1. Medical needs may vary (often chronic conditions, linking patient to primary care)

  6. Non-medical acute need

    1. Desires shelter, Jackson Card, ID card, community resource list, etc.

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