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Care Coordination

Individual/Family Services and Supports

Localized Care Coordination: We know that effective care coordination, especially transition planning, relies on engaging individuals with their own health management process and recovery, encompassing all of their behavioral physical health and social needs. That is why our program features regionally based field teams comprised of Care Coordinators, Certified Peer Support Specialists and Engagement Specialists.

Care Coordination: Some members will be referred to our Care Coordination services when they meet criteria established by the Georgia Collaborative ASO. Care Coordination refers to specialized care management techniques that are available to members at risk or who are encountering barriers to effective care.

These teams work closely with individuals engaged in treatment to help them prioritize their needs and ensure those needs are understood, addressed and met.

The teams ensure individuals have access to the right care in the right setting. They are particularly focused on discharge planning and follow up post-hospitalization. The teams work with the individual, their support resources and community partners to determine any barriers to care and develop a plan to coordinate services to help the individual gain independences and personal growth. Covering large, often rural areas, our local teams recognize the importance of maximizing access to care and making long-lasting connections with community-based resources.

Wellness Recovery

The GA Collaborative provides field –based field Peer Support Specialists to empower individuals served by the program to define and pursue their own recoveries, connect them with community-based resources and work collaboratively with the individual’s clinicians.

In addition, the GA Collaborative employs Certified Peer Specialists to provide telephonic support to individuals who call the crisis response line. They will also make follow-up calls to those individuals who do not require a mobile crisis response to ensure the individual is stabilized and the appropriate linkage is provided. For frequent high utilizers of emergency department services who fail to engage in community treatment, we may send our Peer Support Specialists to the emergency department to meet with the individual and provide support during the crisis.

Peer Support Specialists: Certified Peer Specialists are individuals that are certified in Georgia that have “lived experience” of having a mental illness. This allows them to uniquely and meaningfully connect with others showing by example that long-term sustained recovery is attainable. They support other individuals with a mental illness by promoting hope, recovery, personal responsibility, education, and self-advocacy. They assist their peers in skill building, goal setting, problem-solving, and in helping them build their own self-directed recovery tools, including WRAP.