Care coordination makes the system work

A colleague today asked me if I thought that one of his/her client/patients has been sufficiently evaluated for mental health problems.  A teen, court-involved, DCF involved, dropping out of school kid, who had been seen by outpatient mental health, offered an IEP (declined), sent to a residential home (where she have neurological, psychiatric and medical evaluations suggesting ADHD, ODD and mood dosorder NOS.  She was responding a little to medication and the question was "does she need a neuropsychological evaluation?"

My question was, as always, "Who is following her?"  Here was this nice young lady, without primary care doctor, psychologist or psychiatrist, on mood stabilizers from an inpatient facility with no one in charge of her medication and they we asking me about more evaluation.  "He might need a neuropsych evaluation", I said, "but he really needs a bit more care coordination.  Someone needs to follow up on all of those recommendations from the earlier evaluations.".

He needs, in the end, SOMEONE to advocate and guide him or her through our system of care.   

I guess in the ideal world that would be the parent or guardian.  What happened in this case, i don't know.  Perhaps the parent tried, and hit a wall.  Perhaps the parent didn't try- didn't know that this was part of the job that we all approach with such trepidation.  Perhaps... well, the whole point of this exercise is to make it easier for parents confronting the system.  Will it happen under a CSA?  I suggested to my colleague that the child would benefit from getting a CANS now, so that this patient/client can be ready when the doors to the new system open.  He will clearly need all of the support that we can give her.

Oh, and I was deliberately changing genders in this story because it could have been either.  The point is that there are lots of children out there waiting for the CSAs to open.  I hope that they get up and running soon.