Maria’s story

Maria is a 39-year-old female diagnosed with major depression/bipolar disorder and a history of substance abuse. She enrolled in VIP’s outpatient SUD program in November 2014 and in VIP’s mental health services in January of 2014. Maria moved into the shelter system in May 2014 with her daughter and husband. Her husband, unfortunately, is addicted to substances and he is not engaged in treatment at this time and also not a resident of the shelter; the daughter is with Maria at the shelter.

Health Home connections

Upon initial contact with Maria the care coordinator assessed member needs which included: housing, medical/mental health/SUD, and follow-up with a parole officer. Since engagement, the care coordinator has been able to coordinate services on behalf of Maria with the housing specialist at the shelter where she currently resides. The housing specialist has since submitted an application for low-income housing through the COME NY program. The housing specialist is also in the process of submitting a 2010E supportive housing application as soon as Maria completes and receives documentation of her psychosocial and psychiatric evaluations.

Maria was admitted to the Beth Israel ED on March 2015 for excessive stomach pains and other gastrointestinal issues. The care coordinator traveled over to Beth Israel and had a case conference with the assigned physician. Since then Maria had a colonoscopy done that was long overdue. The results were negative, and Maria will continue to follow up with her gastroenterologist and primary care at VIP’s primary health clinic.

Health Home outcomes

Presently, the care coordinator and Maria’s parole officer have been working collaboratively to stabilize Maria. Her toxicology reports have been positive for opioids due to her adhering to morphine for her back problems. VIP’s SUD program, Health Services, and the parole officer have collaborated and closely monitored client’s use of the above medication to ensure the absence of abuse. By working closely with Maria and her various providers, we have been successful in stabilizing her and preparing her for permanent housing.