Running head: EXECUTIVE SUMMARY

Care Coordination at Lake Whatcom Residential and Treatment Center

Executive Summary
Celestinna Davidson, Christan Mulder Lindsey Helms, Amy Ellsworth
Nursing 442-Summer 2016
Professors Christine Espina and Bonnie Blachly
Western Washington University, BSN Program

EXECUTIVE SUMMARY

Care Coordination at Lake Whatcom Residential and Treatment Center

This Care Coordination project was conducted by a team of Western Washington
University student nurses in conjunction with Lake Whatcom Residential and Treatment Center
(LWC). This group of students worked specifically with the Program for Assertive Community
Treatment (PACT) team members: Todd Borne, RN, and Amy, RN, and Tom, RN. LWC provides
residential and community based mental health treatment and services to adults with chronic
mental illnesses. The PACT team is designed to meet the needs of the most complex clients in
the community with a holistic and individualized approach. The work of the PACT team is based
on collaboration of a multidisciplinary team. The majority of clients working with the PACT
team require assistance with their medical and mental needs and have not benefited from
traditional mental health treatment programs. The purpose of this project and partnership was to
evaluate and assess the way care is coordinated for the mental health population group within
Whatcom County. This report will provide a description of the services provided by LWC and
the PACT team and how their efforts and collaboration with outside agencies are strengthening
the coordination of care for clients with mental health needs.
Problem Description
When patients receive healthcare that is uncoordinated, fragmented or even duplicated it
can be costly and very dangerous. The National Strategy for Quality Improvement has
highlighted care coordination as a priority strategy in the improvement of United States
healthcare. The coordination of care becomes increasingly important and further complex when
caring for patients with chronic mental illnesses (U.S Department of Health and Human
Services, 2014). Health outcomes for the clients being served by the PACT team rely on
appropriate care coordination measures. This vulnerable population is often unable to advocate

for their own needs and they rely on the assistance of organizations and agencies like LWC to
ensure that chronic medical and mental conditions are being appropriately addressed. Clients
with co-occurring mental illness and multiple chronic medical conditions are at an increased risk
of emergency department visits and hospital readmissions due to the complexity in their care.
The clients that are working with the PACT team are among the most severe mentally ill
clients in Whatcom County. There are approximately 70 clients working with the PACT team and
range from 18-70 years of age. This complex group of patients has multiple medical and mental
needs that require consistent support and case management. A huge component of what the
PACT team does is advocating for the clients and connecting them to essential community
resources and developing community partnerships. Resource include linking the client to a
primary healthcare provider, assisting in finding and keeping an apartment, and ensuring basic
needs are met such a food and clothing. The PACT team has three main goals: to keep the patient
out of jail, out of the hospital, and in housing. These clients have a limited ability of resiliency
and with the support of the PACT team multiple hospital admissions and overnight stays in the
Whatcom County Jail have been avoided.
Process and Methods
The identified population group has been predetermined based on referrals to the PACT
team and LWC. Some clients involuntary seek treatment with the PACT team and many
individuals are court ordered to collaborate with the PACT team. Multiple clients have been
released from mental institutions such as Western State Hospital and have contingencies based
on their release to participate with the PACT team. The patients that were focused on for the
purpose of this project were identified by the program coordinator as being high utilizers of
community resources and were medically complex. The patients were assigned to this group

have extensive medical and mental histories, multiple medical conditions and many with
problems involving housing situations, police department encounters and polysubstance abuse.
Each week our team would review the goals of this project as a group and also with the PACT
team RNs. We had the opportunity on four different occasions to go out into the community and
observe the PACT team in action. We observed daily meetings, interacted with the clients in the
community and observed the process of care coordination. We also visited agencies that support
PACT team clients and conducted informal and formal interviews on agency managers.
Results
Through our observations, we concluded that PACT is an excellent program for this
patient population. The PACT team is keeping frequent utilizers of health and criminal justice
resources out of the emergency room, avoiding incarceration, and living in the community. Our
concern is the lack of data that is being recorded. We believe that recording data about the
interventions, community collaboration efforts, and their results can produce evidence for
showing the benefits of the program. The evidence can then be presented to other organizations
that can help with future funding. Research supporting the success of this program can also be
utilized to create similar programs for other communities or patient populations. Additional
funding can be used to purchase a new EMR system, increase the number of staff, and take on
more patients that desperately need these services. It is also a way to continue and enhance
quality improvement of the program.
Also in our observations it became apparent that there is interdependency between
different programs and resources for this patient population. The utilizers of these services are
often transitioning from inpatient hospital stays, incarceration, or homelessness. The PACT team
has relationships with community resources, such as the Catholic Community Services and

compass mental health, and coordinates patient needs with these services. The PACT team also
works actively with the Incarceration Prevention and Reduction Task Force for successful
reduction of incarceration services. These collaborative community efforts have been successful
and reflect the ability for Whatcom community to accept this patient population and
communicate successfully. Other areas for further collaboration in the community is with the
Western Washington University (WWU) Nursing students. The following are recommendations
specific to RN-BSN collaboration, and also for the PACT program.
Recommendations
WWU-Nurse Specific

Arrange Practice Experience times to be congruent with the RN schedules so that

Western students can shadow them.

Third quarter practice experience (CQI class and community health class) can be done
with this facility. Students can assist with the data collection process.

RN-BSN cohort can collaborate with other programs at WWU for data collection and
synthesis.
PACT Program

Data recording and collection in regard to Crisis service usage, history of usage, and care
coordination for prevention. Data synthesis and comparison.

Continue integrating the patients into a supportive community with a focus on assessing
individual patient well-being and continued efforts with communication and collaboration
with supportive community at living environment.

Collaborate with patients to identify their preferable living situation. As patients age, it
might be identified that their needs change.

Conclusions
The PACT team does an excellent job in communicating and collaborating as a team, and
with the community. A positive implication in recording community collaboration efforts and
interventions is eliminating fragmented care and encouraging better resource usage. Patients
utilizing PACT services have been successful in progressing through being an inpatient at a
mental health facility, to living independently and having community involvement. One of the
greatest strengths of this program is the ability to care for the client holistically. The structure of
the program places the client in the center of the care plan. The PACT team strives to empower
each client to function at his or her optimal level. The team encourages clients to focus on their
individual strengths to live the healthiest, best lives they can. A collaborative, community based
approach allows clients with chronic and severe mental illness to create trusting relationships
with their care team, and flourish in their community.
Recording data about PACT services and care coordination interventions could have
implications for large scale funding. If PACT services are shown to decrease costs associated
with emergency room visits and incarceration, more funding could mean more services allocated
to a larger population of mental health patients. In thinking about resource funding and
allocation, there needs to be community collaboration and knowledge of where the highest
density of use is. A class reading that is applicable to this practice experience and our
recommendations is Hot Spotters by Atul Gawande. The article describes a story about two
doctors that analyze data from medical databases to determine who the high healthcare utilizers
are. From that information, they created and coordinated with multidisciplinary teams to provide
holistic care. The results of this were successful, it leads to decrease hospital admissions, and
decreases the amount spent on healthcare. The program described in the article is similar to
PACT services. Mental health patients are high healthcare utilizers and PACT offers them
opportunities to stay out of the hospital, out of jail, and kept in housing. We had the opportunity
to observe many PACT clients who were happily living social, meaningful lives in a home.

References
Lake Whatcom Residential & Treatment Center. (n.d.) Retrieved from: http://www.lwrtc.org
U.S Department of Health and Human Services. (2014). Retreived from:
http://www.ahrq.gov/workingforquality/reports/annualreports/nqs2014annlrpt.pdf