Xavier* is a 16-year-old CountyCare member who struggles with his behavioral health and has been
diagnosed with post-traumatic stress disorder. Xavier experienced a traumatic event that has lingering
effects on him and his family.
Xavier was originally referred to a care coordinator at an integrated health home. The care coordinator
then referred his case to his CountyCare care manager, Lily*. Lily learned that Xavier was having trouble
securing transportation to school and had not seen a primary care physician or a behavioral health
specialist in over three years. Lily sprang into action and completed a health risk screening for Xavier and
developed a care plan based on his needs.
Thanks to Lily, Xavier was able to visit his primary care physician and see a behavioral specialist. Lily
made sure to follow up with both providers to keep Xavier on track. His behavioral specialist and Lily
also contacted the school to help Xavier and his family with any issues he was having – and secured a
bus card for Xavier to get to and from school.
* Names and identifying details have been changed to protect anonymity