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Behavioral Health Home: Where Clients Get Support Navigating Systems

May 16, 2023

Lately, we’ve been sharing a lot about our Crisis and Recovery Centers (CRC), where clients are in residential services and supported 24/7 by our staff. While CRC is an intensive treatment model appropriate for people who need that level of care, our Guild services exist on a spectrum designed to meet various needs and eliminate gaps in our mental healthcare system. 

We sat down with Behavioral Health Home (BHH) Program Manager Alyssa Paulson and some of her team to ask them about the work being done in BHH—a program that exists somewhere towards the middle of our spectrum of services, supporting our clients who are living independently, but require help to navigate the complex systems to keep them stable and well. 

About the Behavioral Health Home Program

The Behavioral Health Home (BHH) program is a health and wellness program that helps clients navigate the healthcare system, access community resources, and manage their symptoms—working with people 18 years and older who have a diagnosis and are on Medical Assistance. 

BHH is designed for people who do not qualify for more intensive case management but need support to navigate complex systems—like county benefits, insurance, paperwork—and community resources, like food shelves. The program is a low-barrier-to-entry program and often an entry point for clients new to Guild. 

Who BHH Serves

The BHH program typically serves clients who are more stable than the individuals receiving.. Targeted Case Management (TCM) and Assertive Community Treatment (ACT). Clients must receive Medical Assistance and have a diagnosis. 

A Cooperative Approach

Program staff works in teams or pods, with each pod having two people. With a high-touch approach, the teams take on a group of clients and interact with them at least once per month, at a minimum. Because the BHH program is highly individualized and tailored to client needs, some interactions with clients are much more frequent.

Pods create a significant advantage for clients because they always have a constant presence. If one team member departs the program or is unavailable, the client is familiar with the other. This continuity in care makes all the difference for clients accustomed to faceless, often confusing systems. 

Stability and Support

BHH acts as a safety net for some of the most vulnerable people in our community who are low-income and meet the financial eligibility requirements for medical assistance. Program Manager, Alyssa Paulson, said, “When you live in poverty, you often don’t have a safety net around you. You don’t have access to the resources money can fix.”

Goals are established every six months, and they are calibrated per client. Sometimes the goals are as simple as getting to a dental appointment or selecting a primary care doctor. Whatever the goal, the BHH teams work with clients to move towards progress in medical and social systems that are so often frustrating and overwhelming for people trying to manage their mental health diagnosis with few resources. Alyssa summed this up by saying, “We can all recognize that there are services out there. However, the system, with all its benefits, is difficult to navigate. Something as simple as needing an address to receive your benefits application- can prove to be an insurmountable task. The unfortunate result is that many get caught on a hamster wheel—working really hard, but with little momentum forward.” 

Intentional Interaction

Clients get the frequency of interaction they need in the individualized program. Sometimes this means investing more time in the beginning while establishing trust with clients who come to the program with negative past experiences, having been let down by the systems intended to support them. The BHH team told us about the early days with one client in the program whose support staff used playing catch to establish rapport, so the team could get the critical information needed to assist the client.

The team also works to help solve problems for the client, alleviating stress during difficult times. They told us about one client undergoing chemotherapy and needing a particular drug from a mail-order pharmacy in Florida. The BHH team helped navigate problems with coverage for the drug, troubleshot delivery issues, and got the monthly cadence automated so that their client could focus on his well-being rather than spending countless hours trying to get his life-saving medication.  

The Impact

The team insists that while the teams at BHH work hard, the clients in the program do the most work. One particular client was struggling with mental health and living in his van. BHH kept showing up, looking for him because, as they said, “That’s our job. We show up to be supportive and meet you where you’re at. We’re not there to judge anyone. We’re just working with where they are at and where they want to be.” This client believes that BHH saved his life, but the team quickly points out that they simply supported him in saving his own. 

Want to support Behavioral Health Home and other programs at Guild?

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