Peer-Centered Transitional Case Management in Clark County, WA

Clark E&T Transitional Case Management

Clark County E&T Transitional Case Management Staff: Meghan Lawless, Peer Support Specialist and Medical Records Tech; Candice Webb, Transitional Case Management Team Leader; Chris Tibbits, Peer Support Specialist; and Richard Whittington, Chemical Dependency Professional/Case Manager.

In early summer 2015, Telecare's existing Clark County Evaluation and Treatment (E&T) program — an acute inpatient program serving 11 individuals — was expanded by Administrator, Dr. Lisa Clayton, to include a new and important service: a Transitional Case Management team (TCM).

The E&T and TCM services are contracted and overseen by Southwest Washington Behavioral Health Regional Support Network (RSN) in Clark County, Washington. The TCM is the first of its kind to operate out of an acute Evaluation and Treatment Center. Its primary purpose is to meet state requirements and ensure that clients are successfully connected to community services within seven days of discharge from acute settings for follow-up and are seen by a prescriber within 30 days. 

"Our team has been able to see everybody 100% of the time within one day of discharge, so our state requirement for follow-up is 100%," said Candice Webb, Team Leader of the Transitional Case Management Team. "We make sure we are helping clients connect with our contracted outpatient agencies. This means they are seeing a clinician within the seven day requirement and seeing a prescriber within 30 days."
Since opening in late May, the TCM team has served more than 30 clients and has had only one readmission. A contributor to their success? Peer support.  

The small and mighty team is comprised of a Mental Health Professional, a Chemical Dependency Professional/Case Manager, and two Peer Support Specialists.

"Peer support services have been invaluable," Candice said. "We have two great peers — one with a mental health background, one with a chemical dependency background — and they have really been able to connect with these clients and make them feel comfortable. They are able to provide a connection with someone who understands and someone that can listen to them, advocate for them, and learn."
One such peer specialist worked with a client who had extreme anxiety when it came to riding the bus, but didn't have alternative transportation to get to his appointments. The peer specialist accompanied him on the bus a couple times per week and taught the client how to reduce his anxiety in the moment. The peer also helped him connect with a rehabilitation program.
Candice supported another client who had previously had a significant suicide attempt and history of alcohol use. After relapsing once, Candice was able to support him to live independently and assist him with a relapse prevention plan. The client has been sober for more than 30 days. By receiving outpatient therapy, the client gained the tools to make choices that enabled him to successfully transition out of the program.

"I am so proud of my staff," Candice said. "They are what makes this program so successful. Their hard work and dedication has really helped people achieve these powerful outcomes."