Ella is an 18-year old girl who spent several years in the child welfare system. She was removed from her home as a result of childhood trauma and abuse and dropped out of school in the eighth grade. With no friends or family, she was forced to live on the streets once she aged out of the child welfare system. Ella would live off her earnings from her part-time job at a local supermarket and her Supplemental Security Income (SSI) benefits, if she received them. She was struggling with alcoholism and several behavioral health conditions, including bipolar disorder and post-traumatic stress disorder (PTSD). Ella has also suffered from a first-degree heart blockage due to some medication she was given as a child. She frequented the emergency room when she was younger for her behavioral health disorders and attempted suicides and had been involved with the local Mental Health Court.
Eventually, Ella was enrolled in Health Home Partners of Western New York/Spectrum Human Services, where she met her Health Home Care Manager—Diana. Diana and the rest of the Care Team used an intensive, person-centered, care transition approach that focused on engagement, working with Ella to identify her immediate needs, and coordinating her care. Shortly after enrolling at Health Home Partners of Western New York, Ella found out she was pregnant. After careful consideration, Ella decided she wanted to carry her child to term and become a good parent. Diana respected Ella’s decision and worked to support her. Together, they reached out to Ella’s mother and worked to restore her relationship with her mother. In doing so, Ella was able to move in with her mother. Ella’s Health Home Care manager connected her to an outpatient mental health and substance use treatment center. She started to attend her appointments regularly and followed through with her providers’ recommendations. Ella’s began to stabilize and she was able to get the appropriate prenatal care she needed. Ella recently delivered a healthy baby girl and now lives with her mother and her daughter.