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The Care Coordination Department is staffed by clinical and administrative personnel who possess appropriate qualifications, and is organized as to ensure that expertise in mental health (MH) substance abuse (SA) and Intellectual and Developmental Disabilities (IDD) is embedded in our practice. Care Coordination practices are grounded in Smoky Mountain Center's (SMC) commitment to be person-centered, emphasize principles of recovery and resilience and family involvement. SMC care coordinators use industry standard technology, care coordination protocols, evidence based practices (EBPs) and clinical practice guidelines. SMC's approach to care coordination is designed to provide each individual with the assistance necessary to choose services and supports to help them achieve their goals.
The Care Coordination department is comprised of several teams and individuals in order to carry out the department's responsibilities and efforts. These teams include the MH/SA Care Coordination team, the I/DD Care Coordination team, the Hospital Liaison team and the Housing Team, which is comprised of employment and housing specialists.
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Community Based Mental Health/Substance Abuse & Intellectual/Developmental Disabilities Care Coordinators
When SMC became a Managed Care Organization in July 2012, the role of administrative care coordination was clearly defined by contract. Care Coordination is family focused, acts as an information hub between agencies/systems, coordinates a community level service plan, develops or ensures development of a crisis plan, focuses on understanding needs in the context of strengths, connecting people with appropriate services, ensures a multidisciplinary coordination and planning with inclusion of community and natural supports and monitors services and celebrates successes. The Care Coordination role focuses on identification, assessment, service planning, referral & linkage, monitoring and risk management & disease management with an emphasis on ensuring access to the right amount, duration and intensity of service for our consumers while reducing escalating cost trends.
SMC provides Care Coordination for two populations: those with defined special healthcare needs and those who are considered high risk high cost. The Division of Medical Assistance defines Special Healthcare Needs for IDD as individuals who are functionally eligible for, but not enrolled in, the Innovations waiver, who are not living in an ICF-MR facility OR individuals with an IDD diagnosis who are currently, or have been within the past 30 days, in a facility operated by the Department of Correction or the Department of Juvenile Justice and Delinquency Prevention. For MH/SA, it is defined by a specific range of diagnostic codes as well as a certain LOCUS/CALOCUS/ASAM score or level of care need or a child who currently, or has been within the past 30 days, in a facility operated by Department of Corrections or Department of Juvenile Justice Delinquency Prevention.
NC General Statute, NC Division of MH/DD/SA Scope of Service Contract and implementation updates defines High Risk/High Cost as anyone who has been assessed as needing emergent crisis services 3 or more times in the previous 12 months OR whose treatment plan is expected to incur costs in the top 20% for all consumers in a disability group. It is also defined as anyone who does not have an defined behavioral health clinical home, involved with CCNC, fits into a set of specialty populations, on an outpatient commitment, adjudicated youth involved with DJJDP or TASC, youth admitted to or discharged from MH/SA residential level III and IV group homes and individuals who currently reside in an ICF-MR home who could be successfully transitioned to a community setting. Individuals involved in the United States Department of Justice and North Carolina Settlement Agreement/Transitions to Community Living Initiative are eligible for SMC care coordination.
If you are a consumer or family member and you or your family member may be eligible for MCO Care Coordination, please contact your regional Care Coordination Manager.
If you are an MH/SA/IDD service provider and someone you serve may be eligible for MCO Care Coordination, please complete a Care Coordination referral form and email a secure copy to your regional Care Coordination Manager.
For further information or if you have questions, please contact your regional community based care coordinator.
Northern Region
I/DD: Tina Clark • 828-265-5315 ext. 4416 • tina.clark@smokymountaincenter.com
MH/SA: Maggie Farrington • 828-265-5315 ext. 4408 • maggie.farrington@smokymountaincenter.com
Western Region
I/DD: Emma Miller • 828-586-5501 ext. 1186 • Emma.Miller@smokymountaincenter.com
MH/SA: Nancy Chastain • 828-837-0071 ext. 1160 • nancy.chastain@smokymountaincenter.com
Central Region
I/DD: John Frazier • 828-759-2160 ext. 3341 • john.frazier@smokymountaincenter.com
MH/SA: Charlotte Bridges • 828-759-2160 ext. 3337 • charlotte.bridges@smokymountaincenter.com
Click here for the SMC Care Coordination Referral/Intake Form
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Hospital Liaisons
The Hospital Liaisons carry out the following critical LME functions at psychiatric hospitals and in the local communities for adult individuals with mental health, substance abuse issues and intellectual developmental disabilities. The Hospital Liaisons oversee care coordination for Adult Admissions Units. Additional Care Coordinators work with the Long Term units, Geriatric Unit and Adolescent Unit. The Care Coordinators do the following:
- Serves as the local LME/MCO representative to state psychiatric facilities to ensure that consumers receive appropriate services with appropriate lengths of stay and that appropriate discharge planning involving all necessary parties is in place prior to the consumer returning back to the community.
- Participates in treatment planning and other activities to coordinate the appropriate level of care and community needs.
- Locate and coordinate community resources that address the needs and desires of the consumer and ensure consumer choice in the selection of a provider.
- Coordinates with the housing coordinator to ensure that they have a place to go prior to their discharge.
- If a person has an Intellectual/Developmental Disabilities (IDD) the Liaison links with the IDD Care Coordinator to assist in coordinating the proper care and discharge planning for the individual.
For further information or questions for the hospital liaison team, please contact Pam Moore, the Hospital Liaison Manager, at Pam.Moore@smokymountaincenter.com
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Housing/Employment Team
The Housing Team provides consultation and expertise in affordable housing resources to consumers, service providers, and other stakeholders. They manage and operate SMC Housing programs, including the Housing Loan program and Shelter Plus Care programs. They update the Housing Resource Guides on the SMC website (located under the Consumers and Families Tab, then Housing Information tab). They are the Local Lead Agency liaison for the Department of Health and Human Services Targeted Unit Program. They also provide information on Fair Housing, Reasonable Accommodations and Reasonable Modifications requests.
The Employment Specialists work with SMC Care Coordinators and service providers to identify consumers in need of employment services who have exhausted paid supports such as Vocational Rehabilitation services. They accept referrals, gather information, conduct job development with potential employers, assist consumers in the job application process, and provide job coaching as needed. They provide education to consumers who receive benefits about the option of work, and how it may affect their benefits.
For further information or questions for the Housing/Employment team, please contact Kristi Case, the Housing/Employment Team Manager, at Kristine.Case@smokymountaincenter.com
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For Immediate Help, Call 1-800-849-6127 For Customer Services, Call 1-888-757-5726 For TTY Calls, 1-888-757-2280
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