Peer Bridger Smooths Transition After Hospital Stay, Connects to Resources

Monarch’s Peer Bridger program assists with transition of individuals from inpatient psychiatric units to the community and their everyday lives, as well as ensuring that the people we support are engaging in treatment for optimum healthcare delivery.

Peer Support Clinician Kenzie Elmore, LCSW, described the program as a connection between mental health crisis stabilization and outpatient providers and resources. “The ultimate goal of the Peer Bridger program is to bridge that gap for individuals leaving the hospital setting and returning to their home because it can be an intense time,” Elmore said.

Peer support specialists find out what is needed to promote mental health recovery, address barriers that may exist and develop a crisis plan. In addition to mental health assistance, Peer Bridger services can include connection to resources for food, housing or employment.

The Peer Bridger program, which was initially implemented in late 2017, was developed to address the critical need for timely follow up after an individual has been hospitalized providing mental health assistance and community resource information, explained Vice President of Operations, Enhanced Services, Lyndril Leonard, MA, LPC. She noted that peer support specialists are given a seven-day window from the date of discharge, following the hospital stay, to connect.

Monarch currently partners with two Managed Care Organizations (MCOs) for the Peer Bridger program, Cardinal Innovations Healthcare and Partners Behavioral Health Management. Peer Bridger staff partner with King’s Mountain Hospital, Cleveland County; Behavioral Health Charlotte, Atrium Randolph; and, Behavioral Health Davidson, Billingsley; and, Old Vineyard Hospital in Forsyth county. Monarch is currently establishing a partnership with Novant’s Forsyth Hospital to begin providing Peer Bridger services.

Peer Bridger peer support specialists include: Dorothy Woods, Alvin “Ted” Boyd, Rico Johnson and Michelle Heatley.

Leonard sees the program’s peer support specialists as strong links in the chain of recovery. “Peer Bridger is about establishing relationships, being able to communicate and share what it is like to go through a mental health struggle,” she said, adding that the peer support specialists’ personal experiences can be positive motivation.

Elmore, who acts as a liaison between the hospital and Monarch services, assists with reviewing referrals and what services would aid in healing. “The peers are the experts. Everyone on our team brings something different to the table. I can share clinical insight and they help me understand the reality that people are facing,” she noted of the team’s collaborative process.

Peer Support Specialist Michelle Heatley incorporates her personal mental health journey dealing with a bipolar disorder diagnosis, as a way to connect with individuals supported. She focuses on being honest about mental health struggles.

“You need to communicate how you are feeling. The feelings not shared get you to the hospital,” Heatley articulated. “If I have to keep control of myself and maintain, I show other people how to do the same. That is why I am so adamant about the mental health field and the care, because I know it works. I am that person.”

Being afforded the opportunity to share her story and helping people is Heatley’s motivation each day. “I make a living telling people my story – the ups, the downs, the good, the bad. I get to help people with that story, and it is my job. That is a good feeling,” she said of her role as a member of the Peer Bridger team.

Heatley said she finds her role connecting the person supported to resources that will encourage and maintain a healthy recovery rewarding: “Like a recipe, we find the way that works best. The same with medication, therapy or whatever resources needed. It’s about putting it together.”

Photo caption: Above right, Peer Support Specialist Michelle Heatley takes a moment with person supported, Brittany Nabinett.