Illustration of Mindoula's Care Coordination ecosystem

The Wolf : You're... Jimmie, right? This is your house?
Jimmie : Sure is.
The Wolf : I'm Winston Wolfe. I solve problems.
Jimmie : Good, we got one.
The Wolf : So I heard. May I come in?
Jimmie : Uh, yeah, please do.


Pulp Fiction (1994)

What specific problems do we solve?

  1. Benefits Counseling and Coordination (including filing for Medicaid, Medicare, SSI, SSDI, food stamps, and housing vouchers)
  2. Life Skills Training
  3. Housing Support
  4. Psychosocial Support & Social Skills Training
  5. Empathetic Support
  6. Problem-solving / Decision-making Support
  7. Medication Adherence
  8. Vocational Skill Training & Career Guidance
  9. Academic Support
  10. Provider Coordination (including linking members with providers in their network and referrals to IOP, PPHP, Residential Rehabilitation, Detox, Crisis Beds, and Addiction Treatment)
  11. Community Resource Support
  12. Emergency Medication Appointments
  13. Family Conflict Resolution / Family Work
  14. Administration
  15. Organization
  16. Legal
  17. Drop-in Support
  18. Crisis Intervention/Resolution

Benefits Counseling and Coordination (including filing for Medicaid, Medicare, SSI, SSDI, food stamps, and housing vouchers)

We help people find new insurance, file claims for the insurance they already have, explain their benefits, copays and deductibles, debate charges with providers and insurance companies, work out payment plans for large bills that members cannot afford to pay in one large sum, and file for public benefits like Social Security (Retirement, Disability, and Income), food stamps, housing grants, free or reduced priced cell phones and internet, reduced metro fare, etc. We also help members complete additional (e.g. annual) paperwork, including all supporting documentation for members receiving public benefits, in order to maintain those benefits. If benefits get cancelled or are changed in an unfavorable way, we help members contest these changes. If a member needs to take time off from work because of a disability, we help with FMLA. If a member needs to take prolonged time off from work, we will file an STD or LTD claim on the member’s behalf and then manage that process for the member.

Life Skills Training

Some of our members have difficulty with foundational life skills that others take for granted.

We teach members these life skills to help them manage things for themselves. We tailor our teaching methods to individual learning styles, and will work will members for however long it takes them to gain confidence and achieve competency. Our most common areas of focus include:

  • Money Management and Budgeting – writing checks, paying bills on time, not overdrafting, living within a budget, negotiating with creditors, paying off debt
  • Understanding Contracts – employment offers, leases, car purchases, credit card offers
  • Cooking and Food Prep
  • Grocery Shopping
  • General Shopping
  • Cleaning, Laundry, and Basic Housekeeping
  • Using Public Transportation
  • Learning Technology – phones, computers, ATMs, tablets, apps

Housing Support

We help members find more affordable housing, safer housing, housing that is disability friendly, and housing that is more in line with with a member’s abilities (e.g. accessible to transportation if a member does not know how to drive or is unable or unwilling to drive). Sometimes our members want to move to a new state or county, and we help with that too. Once a member moves, we help the member locate resources in the community and help them acclimate to their new neighborhood. Our help can range from simply giving a member a list of things that are available in the community, or actually actually taking the member to all the important places the member will need to access (e.g post office, grocery store, restaurants and cafés, etc.) as many times as it takes for the member to feel comfortable.

Psychosocial Support & Social Skills Training

Some of our members do not know how to meet new people. Others do not know how to interact or feel comfortable in social settings. For example, they have difficulty initiating a conversation, maintaining a conversation, recognizing or observing social boundaries (e.g. they will call too much or wait too long to call), or reading social cues. Some of what we do can be as basic as encouraging members to practice getting into the habit of asking follow up questions after “How are you?” or “How is your day going?” For many members we will go out into the community and help them practice how to engage with others socially, and then support them via phone and text when they implement what they have learned (e.g. texting with a member who is at a party but is having difficulty interpreting signals from someone they’re interesting in getting to know better). For even our highest functioning members, there is sometimes a general need for support around social and communication issues. A common example is helping a member learn how to explain treatment, a hospitalization, or a prolonged absence from work to family, friends, colleagues, or a potential romantic interest. Often serious mental illness results in broken relationships that need to be repaired, We assist members in taking proactive steps to mend fences, and rebuild burned bridges. When a member has simply “fallen off the radar,” we help them re-establish connections with friendsand loved ones.

Empathetic Support

While most of our members have therapists, therapists generally work 9am - 5pm Monday through Friday and are often difficult to reach outside of scheduled appointment times. We are available 24/7, 365 days a year. We pride ourselves on the technology we’ve developed that makes us available and responsive for members around the clock. As a result of this availability and responsiveness, members reach out to us in the moment for emotional support, encouragement, and reassurance. We will help members “reframe” negative thinking, find the positive in negative situations and circumstances, and cheerlead for members when they complete a task, have a victory, or accomplish a goal. We will also help members regulate their emotions, for example by talking through situations and events in the moment with them to help them make sure their feelings are proportional to and “match” that moment’s event. Many of our members are lonely and just want someone to talk to. For others, we are the only ones they have. We make that all of our members know that someone is always “there” for them. Our secure Mindoula Messenger app and technology platform have proven vital in ensuring that outreach from our members to us is always answered in real-time, and no member’s important call ever goes to voicemail.

Problem-solving / Decision-making Support

Often people simply do not know what to do in a given situation: Should I purchase this insurance or that one? Should I work full time or part time? Should I go back to my old therapist or find a new one? Should I enter an Intensive Outpatient Program or a Partial Hospitalization Program? Should I rent out my spare bedroom? Should I breakup with my girlfriend? We help members think through their decisions with them, breaking down the pros and cons, and identifying potential consequences and other implications of their decisions (of helping to surface downstream impact they may not have considered). We then help them move the implementation stage of their decision, and provide support for the real work impacts that follow. Along the way, we help our members make healthy choices focused on long term goals and objectives and often help them resist peer pressure and media pressure encouraging short term or superficial approaches to important decisions and problems.

Medication Adherence

Many members we work with do not adhere to their medication regimens for a variety of reasons. Sometimes they do not have enough money to purchase their medications, or have a hard time going to get them picked up. Other times they lose their medications, or get confused about which ones to take. Often they do not like the side effects of their medications, and stop taken them to try to make the side effects recede. We help our members become medication adherent in a number of ways. We arrange for home delivery of medications, and have them packed out in blister or bubble packs or other means of helping them know which medications to take and when to take them. We also help find reduced price alternatives, enroll them in medication cost savings plans, research alternative insurance plans that cover their preferred medications at the best possible rate, and advocate with their providers for alternative medications with reduced or minimal side effects.

Employment Support / Vocational Skills Training / Career Guidance

We help members identify jobs that are both of interest to them and within the scope of their talents, abilities, and skill level. We then assist with job search, applying for jobs, writing resumes and cover letters, and preparing for interviews with informational interviews and by doing mock interviews. Once a member gets a job, we are available to provide on site job coaching, accommodations advice and advocacy (e.g. seeking adjusted hours or tasks), and assist with conflict resolution to resolve conflicts that may arise between the member and their employer or a coworker. If a member needs to take time off because of a disability, we can help them with unpaid leave under the Family and Medical Leave Act, Short Term Disability, and Long Term Disability. For members entering the workforce for a the first time or returning to the work after an extended absence, we help members find volunteer positions to help them increase their employability, learn new skills, gain references, and improve their resumes.

Academic Support

For many of our members, college is a time when behavioral health challenges first begin to emerge. Not only is stage of early adulthood a time when the initial onset of mental illness often occurs, but very often the stressors of college and the experience of first being on one’s own without traditional and long standing supports prove difficult for members who have an underlying mental health condition. We provide assistance to help college students establish themselves within college support resources (e.g. disability services & campus counseling centers). We also advocate for necessary accommodations (e.g. increased access to professors, clearer assignments, extended deadlines, earlier class registration, untimed tests, extra credit work, etc.), and help members connect with social clubs on campus. We also help our members organize and manage their work so they do not fall behind, and if they nevertheless fall behind, we help get them back on track. We offer “supervised study” for students who are having a hard time accomplishing their tasks and staying focused. For students that are facing learning challenges, we assist in finding, vetting, and hiring tutors to help them achieve their learning goals.

Provider Coordination (including linking members with providers in their network and referrals to IOP, PPHP, Residential Rehabilitation, Detox, Crisis Beds, and Addiction Treatment)

We help members people find new providers (e.g. therapist, psychiatrists, specialists, PCP, IOP, PPHP, residential, detox, etc.) that are covered by their insurance (or are affordable if private pay). Once the member has a solid team of providers, we help members make appointments, get to their appointments, and will sometimes accompany them to their appointments (especially if they are concerned about their ability to get there unassisted, are anxious about the appointment, or find it difficult to remember instructions from their provider). We also coordinate the member’s physicians and other providers, ensure that every provider knows what the providers are doing, and help the member maintain up-to-date medical records. We can also advocate at provider appointments for a certain course of treatment (or against a certain course of treatment) in line with the member’s wishes. With the member’s consent, we also update families (especially ones that do not live in the area) about how treatment is progressing, what a member’s future course of treatment will be. Families often give give us questions for the providers, which we relay to the providers and ensure that the questions are answered. This is particularly important when people go to large scale and costly treatments (e.g. inpatient residential placements), or when a family wants to make sure a loved one is getting the best treatment possible within a defined budget, or when the loved one is not capable of interacting with a provider on his or her own and then reliably relating information back to the family.

Community Resource Support

Many of the members we serve do not initially know what resources are available to them within the community. These resources can be mental health services (e.g. publicly funded centers, clinics, and programs), addiction recovery based programs (e.g. drug, alcohol, sex/porn, gambling, etc.), support networks (e.g. grief, depression, anxiety, over-spending, overeating, divorce, trauma, rape, etc.), social supports (e.g game nights, movie clubs, book clubs, organized sports, political activism, LARP clubs) – you name it. We help connect members to programs, services, and resources in their community based on their needs and interests. This is particularly important because many of the members we work with are socially isolated and have a hard time “getting out there” to meet new people, or may need to form new social connections because they have lost touch with or broken their previous relationships, or is other cases, or may never had formed meaningful relationships and need help getting started.

Emergency Medication Appointments

We help our members get emergency appointments for medications, oftentimes when there are few alternatives. Sometimes members have not filled a prescription they received from the hospital (e.g. because they could not pay for the medication). We assist in getting them appointments, and then following through with them to ensure there is an option for them to receive their medication as soon as possible. Other members have discharged from emergency rooms where they were not prescribed medications. We help them get an appointment with a psychiatrist or other prescriber as soon as possible. Still other members are heading into crisis and need rapid access to appointments for psychiatric assessment and psychotherapy. We help them get priority access to providers who can write prescriptions needed to address the emerging crisis.

Family Conflict Resolution / Family Work

Mental illness, especially serious mental illness, can cause a lot of family conflict and tension. Conflict and tension often becomes the norm because families often sufficient information about how to support a loved one with mental illness, and because the family member with mental illness is often prone to take actions that isolate him or her from others. We work with families to understand what their loved one is going through, help them find better ways to engage with their loved one that works for everyone, help set appropriate boundaries and establish reasonable expectations. In severe cases, when contact has been severed, we may help act as an intermediary and serve as a single source of contact between the member and his or her family (e.g. when a loved one has harmed a family member and the family member wants to support the loved one but doesn’t want to have contact with him or her anymore). It is important to note that sometimes the Mindoula member we working with is the family member that does not have the behavioral health challenge. This may occur, for example, when a loved one is too impaired to utilize or engage with case management and the family member needs help “navigating the system” to learn what is best for their loved one and what to implement on their loved one’s behalf.

Administration

We do everything and anything administrative one can think of in this category. For example, we sort mail, help pay bills, compile everything needed for taxes and court hearings, place orders for basic household supplies, manage calendars, make appointments, and make thousands of photocopies… Essentially we function as glorified secretaries or personal assistants. When addressing the day-to-day tasks on a “To Do” list or a set of action items is the answer to help a member move forward in achieving his or her goals, we’re more than happy to roll up our sleeves and get to work “sweating the small stuff” for the member so that some of the big, important stuff can happen without distraction.

Organization

We can do anything from massive organization projects (e,g. cleaning out house after years of hoarding behavior because a member is being threatened with eviction or the loss of their children due to unsafe living conditions) to the most basic tasks (e.g. helping a member learn how to use a day planner app). Many of our members have meaningful challenges with organization both from a time perspective (e.g. the member can not get places on time as scheduled) and with their belongings (e.g. can’t keep track of important documents). We come up with organization solutions to help keep our members on track. This can range from implementing complete organizational systems with our members, to doing smaller organizing tasks with them, to providing periodic reminders, to planning out calendars and scheduling appointments and meetings for the member. Where there is need for micromanagement of the things that help organized the lives of our members, we’re there to provide as much or as little of this support as necessary to help keep them on track.

Drop-in Support

All our Concierge Case Management Program members are welcome to drop into our office in Silver Spring without an appointment between the hours of 7:30am ET and 5:00pm ET, Monday through Friday, to “hang out” with us so we can check on them while they work on things. Our drop-in service has been described by some of our members as a “study hall” reminiscent of college. Members sometimes just do better hanging out in a group and being accountable to others. Often members use this time to apply for jobs, catch up on paying their bills and budgeting, and completing schoolwork. We will lovingly pester them every five minutes or so (and sometimes more frequently) to make sure they are staying on track and doing what they’ve committed to do. We find that a lot of our members like having a place to go that is outside of the house, where people will be kind and supportive, and where, at the end of the day, they can report on what they’ve accomplished, knowing they will get from us an enthusiastic and supportive response.

Crisis Intervention / Resolution

We deal with some kind of crisis every day of the year. Mindoula case managers are generally the ones who take the lead in negotiating a resolution to the problem. For families, friends, therapists, psychiatrists, lawyers, trustees, etc.,we are the ones who will drop everything, jump in, and know what to do to get results, regardless of uniqueness or difficulty of the situation. Common crisis examples include: a suicide attempt, a homicide threat, a standoff with the police, an eviction, rape accusation, or DUI. Essentially, whatever it is, if you call Mindoula, we will help you figure it out and get through it.