Sarah Thomson is 27 years old, divorced mother of Billy Thomson, age seven, who live together in a tiny apartment in a run-down, non-rent controlled building in Temperance, MI.   Sarah has asthma and an opioid addiction, for which she is currently in Medication Assisted Therapy (MAT), and which also caused her to develop Chronic Kidney Disease (CKD).   She is 6 months pregnant, and has several nonmedical issues with food, housing, and transportation.   

Billy was born with Neonatal Abstinence Syndrome (NAS), and as a preschooler watched far too frequently as Emergency Medical Services came to the house to resuscitate his mother.  In spite of all these Adverse Childhood Events, he has never  been screened or diagnosed for any developmental disabilities, even though he has been held back to repeat first grade.

When Sarah was married and had health insurance through her husband’s employer, Dr. Carla Sanchez, Sarah’s Primary Care Physician, worked with Sarah to establish an integrated care team for her and Billy.   Sarah’s Care team consists of

Dr. Sanchez and her office’s clinical staff

Dr. Jordan Emmett, an Ohio-based MAT Treatment provider

Billy’s care team consists of

Dr. Amy Taylor, a Pediatrician in Dr. Sanchez’s practice  

Florence Whitaker RN, the School nurse at Billy’s school in the Monroe County Independent School District  (added when Billy entered first grade)

Sarah schedules an appointment for her annual well visit with her primary care physician, At the appointed time, Sarah arrives at the office of Dr. Sanchez.  While waiting to see Dr. Sanchez in the exam room, Samir Anand LPN, one of the practice’s clinical staff, collects Sarah’s vital signs and asks Sarah to answer a few questions from a social risk screening tool the practice is using. Samir explains Dr. Sanchez’ practice is screening all patients as part of their annual well visit exam. Samir provides Sarah with a mobile tablet with the electronic questionnaire.   Sarah answers the questions and returns the tablet to Samir. Samir uploads the completed questionnaire into the EHR.

Dr. Sanchez enters the exam room and begins the consult inquiring how Sarah has been since their last visit. Sarah shares that over the past year the family has experienced significant life changes including Sarah separating from her husband, who is not paying child support, and on top of it she’s lost her health insurance.  She is struggling living off one salary to pay for rent, childcare, and food. She feels overwhelmed and guilty that she comes home too tired to do anything but get Billy fed and ready for the next day.

Dr. Sanchez uses her EHR to review the results of the social risk screening and history for Sarah. She examines Sarah and notes Sarah is gaining weight and her asthma is worse. Sarah acknowledges she saves money by buying low-cost foods such as macaroni and cheese and pizza. She rarely buys fruits or vegetables because they are more expensive and the neighborhood in which she lives is considered a food desert, i.e. Sarah has to travel a long way to find a grocery store that sells fresh vegetables and healthy food options.

She also notes that she cannot always afford medications so she spaces out her asthma controller medication to every other day instead of every day. Dr. Sanchez inquires whether Sarah has talked to her landlord about mold or another allergen remediation. Sarah confirms she has not. Dr. Sanchez tells Sarah the screening responses indicate distinct risk around food insecurity, housing instability and quality, and transportation access. Sarah confirms she needs help with these are three areas. To address the asthma concern, Dr. Sanchez and Sarah identify goals to reduce asthma triggers in the home and minimize the cost of medications. Dr. Sanchez reviews the cost of Sarah’s asthma controller medication and determines an equally effective, lower cost medication is available. She also confirms Sarah is eligible to receive an asthma home visit. Dr. Sanchez places an order for a new asthma medication and submits an electronic request for an asthma home visit to assess for asthma triggers.

To address the three social risk factors, Dr. Sanchez and Sarah identify goals to 1) find more affordable housing solutions and healthier food options; and 2) find more efficient transportation options. They discuss an action plan to address the goals that involves Sarah working with a care coordinator to identify and secure available services and supports. Dr. Sanchez refers Sarah to Reeza Shah RN, a care coordinator in Dr. Sanchez’s practice who can help connect Sarah to available resources, either those available in-house or those available in the community.  Dr. Sanchez adds Reeza to Sarah’s integrated Care team. 

Samir returns to the exam room and works with Sarah to find another date/time to schedule a telephone consultation with Reeza. Samir schedules the appointment with Reeza for the following week and a follow-up appointment with Dr. Sanchez within three months of the appointment with Reeza.

The following week, Sarah meets with Reeza.  Reeza has reviewed Sarah’s care plan and identified several resources available to support the care plan goals.   Reeza and Sarah use the Michigan Assistance and Referral Service (MARS), and confer with Ellen Davis, an Eligibility Specialist in Michigan Department of Health and Human Services, to determine Sarah’s eligibility for Michigan Medicaid’s Healthy Michigan, Healthy Kids, Maternity Outpatient Medical Services, SNAP benefits and WIC services.   Reeza also contacts Michael Frank, an asthma home-visit provider, to arrange for an asthma site visit.

Michael contacts Sarah by phone to schedule the asthma site visit. Michael conducts the assessment and discovers there is slight mold in the apartment that is aggravating Sarah’s asthma. Michael emails Sarah, Dr. Sanchez, and Reeza a copy of the home-visit report and recommends Sarah be referred to a   housing coordinator. Reeza reviews Michael’s report and uploads into the EHR. Within 1 week, Reeza emails Sarah with the names of two housing coordinators.   

When Sarah has her follow-up visit with Dr. Sanchez, she documents the agreed upon health concerns, patient goals, action plan, and referral (planned intervention) in the care plan within the EHR.

One day Billy’s First Grade teacher, notices that Billy has come to school in a very drowsy condition, falling asleep several times at breakfast and in early morning classes, and sends Billy to see Florence Whitaker, the School Nurse. 

Florence begins to take Billy’s vital signs and record them in the School’s EMR system.  While she is talking to Billy she happens to notice what looks like an empty prescription bottle in his book bag – when she examines it, she finds it is from his mother’s buprenorphine prescription. She immediately suspects that this is the cause for the drowsiness and now opens a triage instrument to ask Billy some questions and record her observations of her behavioral concerns.  The Triage tool guidance suggests an intervention of notifying the School Assistance Team, which includes besides Florence, the Principal, and Gerald Brown LSW, a social worker in the Michigan Department of Health and Human Services (MDHHS) Monroe County office, who in turn calls in the MDHHS Child Protective services unit.

Billy gets placed in a Foster home and Gerald works to get Billy enrolled in a Home and Community Based Services (HCBS) Medicaid Waiver program for Children with Substance Use Disorder.   Gerald also works with Lisa Jones JD, Billy’s court appointed Lawyer-Guardian Ad Litem (LGAL), and Dr. Amy Taylor, Billy’s pediatrician, to add Dr. Peter Gutierrez of the Monroe County Mental Health Authority to Billy’s Care Team, and use Consent2Share to Consent to share medical information between Dr. Taylor, Dr. Gutierrez and Nurse Whitaker.

Dr. Gutierrez performs an assessment and finds Billy has several developmental, behavioral and health care needs, which are recorded in the plan of care which are recorded as an observation and documented using the Subjective, Objective Assessment and Plan (SOAP) note.  The Plan of care includes various interventions, including counseling, an Individualized Education Plan (IEP), and screenings for other developmental factors such as Audiology, Vision, etc.   In addition, a Machine Learning predictive model used by Dr. Sanchez’s practice has picked out Billy’s situation as high risk for developing asthma, high risk for developing Severe Emotional Disorder and Sarah’s expected child as high risk of being born with NAS.

Dr. Sanchez makes a note to discuss the NAS issue with Sarah at her next appointment.  

Dr. Taylor sends a note to Gerald about Billy’s risk, who in turn communicates that with LGAL Jones.

Florence, Gerald, Dr. Taylor and Dr. Guitierrez all collaborate to deliver on this plan of care, and share the results via their respective devices.  Mrs. Jones can also be informed of Billy’s progress. Ultimately Lisa and Gerald will work on getting Billy reunified with Sarah, at which point she can follow along on this progress as well.