At 23 years old, David* has complex behavioral and physical health needs, including a diagnosis of schizophrenia and medical conditions caused by malnourishment. He had been living in a tent for the past five years, with frequent hospitalizations for both physical and mental health issues. Due to limited resources and significant resistance to support, David found it challenging to accept behavioral and physical health interventions.
A care manager at Aetna Better Health of Illinois, Stefany*, reached out to David at least once a week to build a trusting, therapeutic relationship. Before his most recent hospitalization, Stefany referred David to Brave Health, where he completed an intake appointment. Recognizing his nutritional needs, she also arranged for nutritional supplement drinks to support his health. And she helped schedule Modivcare rides to ensure David could attend his medical appointments. They worked together to address his resistance to therapeutic support, with Stefany providing education about his mental health condition and the importance of managing his medications.
Stefany also introduced David to Collaborative Bridges, a network of three agencies that supports mental health needs on Chicago’s West side. She obtained David’s permission to make a referral. When he was hospitalized, Collaborative Bridges was notified and agreed to visit David there, building a relationship and offering support. Through this connection, David began engaging with C4—a program that provides a caseworker to help him navigate resources, such as completing his SSI paperwork. They provided home visits and are working to connect David with resources to promote consistent treatment engagement and reduce future hospitalizations.
Since his discharge, David has moved in with his mother and continues working with his caseworker from Collaborative Bridges. He has attended a follow-up appointment with his primary care provider, is taking his medicine and is now living a healthier and more stable life.
*Member name changed to protect privacy