Program Spotlight: Integrated Care Clinic
Lisa Mann, Clinic Nurse Manager, speaking with a client
“Those in the public who have privilege should use it in the service of those without such privilege, and support community leaders and social policies that will address social determinants of mental health.”
FrontLine Service Integrated Care Clinic Team
Donivan was in his late 20s and had hit a wall when it came to dealing with his symptoms of mental illness while also trying to find his path out of homelessness. Because of his circumstances and the nature of his symptoms, Donivan was experiencing many obstacles to initiating or maintaining treatment but wanted to find ways of bringing his symptoms to a more manageable level and establishing a more stable, secure, and improved quality of life. This turning point eventually brought him through the doors of FrontLine Service’s Integrated Care Clinic for the first time.
The Clinic is one of the benchmark programs so vital to the agency’s core. The unique difficulties often faced by the population FrontLine serves—such as difficulty with transportation to appointments or keeping their phone turned on, factors people take for granted—become obstacles leading to fragmented care and a host of related complications. The services, and the way they are delivered, embody the FrontLine values of meeting people where they are and letting them lead the way in their care, establishing what success looks like for them. As the Clinic team states, “Success looks different for every client,” whether that means reduction of symptoms, improved mood stability and relationships, or decreased substance use or hospitalizations. The Clinic offers flexible access to trauma-informed, client-centered care that’s difficult to find elsewhere and has been structured so those with the highest barriers to care can have support in navigating those barriers.
The core of the clinic team consists of three nurse practitioners who specialize in psychiatry, and one physician who specializes in forensic and community psychiatry as well as two nurses, a nurse manager and, one day per week, a child psychiatrist. Individuals who have difficulty getting to their appointments have the option to walk in and wait to be seen. The Clinic’s team knows well that when someone reaches their primary success goals, it tends to lead to achieving other successes including housing, completion of probation, or employment.
Working with his care team, Donivan mapped out his treatment plan and goals. He declined medication but wanted to engage in other services, continuing to visit his care provider. As Donivan saw over time, the symptoms of his illness and continued displacement made it difficult for him to make his appointments, and he was still struggling. FrontLine’s housing first policy made it possible for Donivan to become a resident at a PSH site without having to meet requirements he wasn’t ready to meet, like taking prescribed medication. When his symptoms caused him to face a possible eviction, the Clinic’s team took the time to help Donivan feel safe enough to begin considering other options for his treatment plan going forward so he could maintain housing. He moved into a group home where he has support with medication compliance and appointment attendance, and the option for outreach visits by his provider and nurses. He remains engaged with the clinic and expresses gratitude that he is on medications and in stable housing.
The Clinic staff would like to see a more compassionate public response for the individuals they serve, saying, “If everyone in the public would learn about root causes of homelessness and adopt a trauma-informed outlook regarding individuals with mental illness, addictions, and those with criminal justice involvement, this would help our clients.”