BCCS Targeted Care Management (TCM) Program Casts a Life-Saving Net

Targeted Care Management (TCM) Program Casts a Life-Saving Net

By her own account, Angel Fanta should not be alive. Not long ago, she was on the verge of hopelessness.

“I was suicidal,” she said, “I have a lot of problems, physical and mental.”

Those challenges made it impossible for her to work, which left Angel Fanta without insurance or the ability to pay for care. “I was going to therapy for years, and when I didn’t have a job, I couldn’t afford it,” she said. The reaction from her counselor at the time was to-the-point. “They told me, ‘Until you’re able to pay, we can’t help you.’” 

She was also running out of the medication that settles the taunting sounds and visions she experiences without it. “I have demons I’m fighting every day,” she said. “I called other places, and they were either full or they didn’t take people without insurance.”

Finding Hope at BCCS

That’s when Angel Fanta reached out to Brandywine Counseling and Community Services (BCCS). “I told them I didn’t have insurance. I’m not working. I need help,” she said. “They took me in.”

She was referred to BCCS’s innovative Targeted Care Management (TCM) program. TCM pairs individuals with behavioral health conditions, including co-occurring disorders, to a Peer Care Manager. With a holistic, cross-agency approach, TCM assists with advocacy, mentoring, aid applications and connecting clients with community-based medical, mental health and substance use treatment providers.

At the center of TCM is the Peer Care Manager, whose social work background, shared-life experiences and broad knowledge of local and state-wide services can rapidly move a person from crisis to hope. For Angel Fanta, that was Jesse Simmons.

“We went into full scramble mode,” said Simmons. That included a suicide prevention plan to ease Angel Fanta out of crisis, a counselor from Jewish Family Services who had worked with her through another agency, and a nurse practitioner. BCCS also helped Angel Fanta refill her life-saving prescription.

“I started to feel OK,” she said. “I had people I could call. I’m not stuck all day with my demons.”

BCCS then helped Angel Fanta enroll in Medicaid, and continues to assist with her disability claim. “They took the time to help me; they took me to social services,” she said. 

Catching People When They Fall

BCCS Director of Business Development Monica Alvarez, MSW, said the TCM program is designed for people who, like Angel Fanta, fall through the cracks. TCM is statewide and open to anyone with a referral from with BCCS or an outside agency.

For Simmons, TCM is the type of program that empowers him to be most effective: client-centered and silo-free. Peer Care Managers work with clients to identify their goals, then connect them with community-based services to help reach those goals. 

“The clients know themselves better than we ever can,” he said. “The TCM Care Managers are hired by BCCS but we’re able to search across the county, so our clients can find the services that are best for them. I love the freedom to make this client-centered.”

A Network of Caring

Alvarez said TCM is fostering cooperation between state and community agencies to fill gaps in the behavioral health safety net. 

“One agency can’t do it all, nor should we,” she said. “With TCM, we provide a single place for referrals and cast a wide net. BCCS doesn’t have all the resources or all the expertise, so let’s work with others.” The program’s only limiting factor is the need for more TCM Care Managers.

For Angel Fanta, TCM comes down to a simple fact: She is alive and doing better. 

“I felt like everyone had given up on me,” she said, emphasizing the importance of her TCM care manager sitting down with her to build goals and then help her meet them. “If it wasn’t for Jesse, I’d be six feet under.”