Behavioral Health for Children and Youth (InCK NIC/MITATAC 2020 Story - Index Person: Jameson Thomson)
Sarah Thomson, now age 30, is a medically complex patient with multiple chronic conditions (asthma and heroin-induced nephropathy, which has not yet progressed to End-Stage Renal Disease). She is still under court-ordered Medication Assisted Therapy (MAT) for Opioid Use Disorder. She has been divorced from Air Force Technical Sergeant John Thomson for three years and has been raising her two children as a single parent. They live in a run-down area of Temperance, MI, near a furniture manufacturer and a large farm, with associated air and water quality issues.
Since we last checked in on our scenario family, Sarah gave birth to a daughter, Madison, who is now 3 years old. Like her son, Jameson, Madison was born with Neonatal Abstinence Syndrome (NAS). Jameson, who is now 10 years old, also has asthma. He has no medical home, gets minimal well-child care, and receives most of his healthcare at the ER or urgent care facilities He has watched far too frequently as Emergency Medical Services personnel came to his house to resuscitate his mother. He has been in and out of foster care and has been receiving behavioral health therapy ever since Child Protective Services intervened as a result of his Adverse Childhood Experiences (ACEs), which were directly and indirectly due to his mother’s addiction.
Jameson was held back to repeat first grade but has never been screened for nor diagnosed with any developmental disabilities. Jameson has been traumatized in many ways – being separated on-and-off from his mother and from his father for year; moving away from his friends each time he was placed in foster care; living in care with a different, unfamiliar family each time; and being placed repeatedly into new schools in which he knew no one. During the same period, he has been detached from his personal support system, even as he has been challenged by the new experiences of meetings with an overloaded case manager, appearances in family court, and the stress of his mother’s addiction and his father’s ongoing absence.
Jameson becomes withdrawn at school and testy with his foster parents. When he moved into his most-recent foster placement, he left his medications behind and has neglected to continue his asthma-controller inhaler treatments; it’s no surprise that his physical and mental health have declined. In addition, although he is getting behavioral health therapy, Jameson uses drugs and alcohol to cope with his misery and anxiety.
One day Jameson’s fourth-grade teacher notices that he has once again come to school appearing to be under the influence. She sends Jameson to see Florence Whitaker, the school nurse, and writes up an incident report in the School Management Information System (SMIS) on her laptop.
Florence begins taking Jameson’s vital signs and recording them in the School’s Electronic Medical Records (EMR) system. She suspects misuse of opiods to be the cause for Jameson’s drowsiness, so she opens a triage instrument to ask some questions and record her observations. The Triage tool guidance suggests an intervention: Notify the School Assistance Team, which is made up of Florence, the principal, and Gerald Brown LSW, a social worker in the Michigan Department of Health and Human Services (MDHHS) Monroe County office.
After discussing the case, the team determines there is enough evidence to trigger a SMIS-generated Mandatory Report to Child Protective Services. Jameson’s child welfare case manager receives the Mandatory Report and now needs to work with the boy’s assigned primary care physician, a psychologist, teachers, foster parents, and the family court to revise Jameson’s Service Plan to ensure he gets additional behavioral health support and substance-abuse rehabilitation. In addition, the case manager initiates a Health Care Plan with Jameson’s Primary Care Coordinator via a FHIR Care Plan Resource.
The Primary Care Coordinator evaluates the requested Care Plan, updates it to reflect medical necessity, and generates a FHIR eLTSS Resource (electronic Long-Term Support Services request with Care Plan and associated Referrals), which is sent to each of the behavioral and physical health specialists needed to help Jameson get well.
Desired Outcome: With appropriate cross-domain social services, case management, and health care coordination, Sarah may finally be helped through successful completion of substance-abuse rehabilitation; her daughter, Madison, could be provided with better early-life care; Jameson could receive appropriate healthcare and therapy; and, once Sarah is clean and sober, her son could be re-integrated into the family.