Abby, a Health Home Care Manager, met her Health Home member, Madison, in the hospital after she was admitted for her substance use disorder. Abby got to know Madison while she was in the hospital and learned that she was recently reunited with her daughter after being released from jail. Madison had previously been diagnosed with major depression and bipolar disorder. She also has a history of substance use which was what landed her in this hospital this time. Madison told Abby that she wanted to get better but didn’t know how.
Abby promised that she would help Madison. Once Madison was discharged, Abby helped Madison enroll in VIP’s outpatient substance use disorder (SUD) program and access VIP’s mental health services. With no actual home to return to, Abby moved Madison and her daughter into a family shelter while she helped Madison find stable housing. Since Madison had been neglecting her health, Abby connected her to various providers to address her stomach pains, gastrointestinal issues, and back pain. Madison needed opiates for her back problems; however, her healthcare providers were wary of putting her on opiates given her history with substance use. In response, Abby convened a meeting with the housing specialist at the shelter, parole officer, and the healthcare providers to develop a plan to monitor her opiate use to ensure she was not abusing them.
Madison is still using the opiates for pain but not has not shown any signs of abuse. Her application for supportive housing was approved, so Madison and her daughter now have a permanent place they can call home. Madison continues to work with Abby to manage her health.