Even before patients leave the care of an inpatient behavioral health facility, Sarah Weltzer is working behind the scenes to help them take the next steps to better health.
Sarah is a mental health counselor by training, and her work as a care coordinator is to connect Health First Colorado members in Larimer County, Colo. with behavioral health needs to resources to improve their health.
“It’s not always easy for people to understand the resources and services that are available for them to use, or to advocate for themselves,” Sarah says. “When we’re able to help people, that, in turn, improves the health of the community as a whole.”
That means proactively reaching out to inpatient mental and behavioral health facilities to work with staff and identify needs a patient may have before they are even discharged.
“My focus is behavioral health, so often, that’s making sure they get follow-up appointments with a mental health counselor, or with a primary care physician if the member doesn’t already have one,” she says. “Or maybe the member needs food resources, help getting a prescription filled, social support, or help getting them into community-based programs. I can help them connect.”
Ongoing care with a community-based provider is critical, and sometimes finding a provider with availability when a patient needs it is a barrier. “It can be frustrating for them to wait if they can’t get in right away,” Sarah says. “I try to overcome that barrier by connecting with the provider to see if there’s a way to get in sooner.”
Care coordination that bridges both behavioral and physical health is a big part of the job, too. Sarah calls members after they’re discharged from an inpatient mental health stay to ensure they’re connected to care services and community resources they need. She works closely with the local mental health clinic, Summit Stone, to coordinate ongoing outpatient care, and often involves members directly to enable self-advocacy.
“When they have questions relating to behavioral or mental health benefits or services, I like to do a three-way call to connect them to the person who provides the services. That really incorporates the member and makes them an active participant in their own care.”
Sometimes Sarah’s assistance is more hands on, like when she attends a medication management appointment with a member to take notes. “If the member isn’t clear on something the doctor said, I can look over my notes or I can contact the provider to get clarification.”
Sarah has been in the role less than a year, and is still learning about resources in the community. She often taps into the combined wisdom of the nine other care coordinators in Larimer County that work alongside her. Together, they coordinate care to meet the physical, behavioral and mental health needs for about 50,000 Health First Colorado members. “We each have our own area of focus, but we work together—we are always collaborating. It’s a real benefit for the members to be able to work with one care coordinator, but essentially have all 10 of us supporting them.”
Each member, each case, is unique, and that keeps Sarah digging for answers and resources. “I like that it’s different every day,” she says. “I’m always learning something new, which is awesome, because you can never know enough. There’s always a service I may not be aware of. But then I research for the member and discover a resource that I didn’t know was even out there. And now I have that in my pocket to share with other members.”