The Montgomery County Department of Health and Human Services has launched an effort to address the negative health care outcomes associated with poor housing and other social determinants of health among persons with serious mental illness.

The Community Based Care Management (CBCM) Program works to mitigate the effects of housing insecurity on inpatient psychiatric stays, frequent readmissions, and unnecessary use of emergency departments.

The CBCM program provides MCES with a Community Health Worker to assist our Continuity of Care caseworkers with identifying housing problems and other social issues that may have consequences for patients’ physical and mental health. Patients who are members of Montco Behavioral Health Choices, the county’s managed Medicaid program, who participate in CBCM will receive an enhanced discharge plan targeting their full range of needs.

Before the patient leaves MCES, all the key service providers involved in the discharge plan will come together to assure aftercare is coordinated. The patient will be part of this session and the MCES Community Health Worker will play a central role in mobilizing post-discharge services tied to the patient’s critical needs. Follow-up will occur at seven-day and 30-day intervals after discharge to assure services are proceeding according to plan.

The CBCM program is voluntary and all eligible patients will be screened and have the opportunity to participate. Magellan Behavioral Health and Carson Valley Children’s Aid Housing Resource Center are also program partners. The program has been operating at MCES for several months and has had success in achieving these outcomes among participating patients:

– Stable housing arrangements for homeless patients and rapid rehousing for those whose housing was put at risk by hospitalization

–  Stronger engagement with medical services to address chronic health condition

–  Less frequent admission to MCES

Overall, the program stands to both improve the quality of life and community living for persons with serious mental illness and reduce expenditures for inpatient psychiatric care.

Co-provider funding for the project is through a state grant.