This presentation uses case studies from a variety of target populations to highlight challenges and successes when serving clients in an integrated healthcare environment. This workshop will include an enhanced care coordination panel representing various Integrated Delivery Network (IDN) Regions. 

Region 1 will explain how their copilot team serves a specific Medicaid population with a combination of complex medical needs, complex basic needs (housing, food, transportation), and mental health support needs. 

Region 2 will share their Family Choices program which uses the NH Wraparound intervention model and is available to pregnant and parenting families with children through age 6. 

Region 3 will present their Integrated Dual Diagnosis Treatment project to treat those with co-occurring SUD and mental health diagnoses. 

Region 7 will describe a Community Health Workers’ role as the bridge between the patient in the community and the providers and services they need to access. 

At the end of this session, participants will be able to describe different approaches to care coordination and identify barriers and mitigations that occur while providing care coordination for various target populations as well as describe at least 2 approaches to sustainability of care coordination models.

Panel Presentation (see below for speaker information) 

Region 1:  Jennifer Seher BS is the Program Director of the Aging and Disability Resource Center (ServiceLink) in the southwestern part of NH.  She has worked collaboratively with NH BEAS and UNH to pilot U.S. Administration on Community Living (ACL) funding pilot for the current implementation of the NH Family Caregiver Program.  In 2013 she worked in collaboration with NH BEAS, UNH CACL, and Cheshire Medical Center-Dartmouth Hitchcock Keene to pilot the Coleman CTI model for high risk patients transitioning from hospital to home. She is currently working in collaboration with Monadnock Family Services, Cheshire Medical Center-DHK, and other community partners to implement a program named Copilot which builds on the success of the ServiceLink care transition work with CMC-DHK.

Jennifer is a Critical Time Interventionist certified through the Center for the Advancement of Critical Time Intervention and a Master Social Work candidate through the University of NH.

Region 1:  Glen Lawrence, MA is the Director of Adult Services at Monadnock Family Services.

He is responsible for the administrative and clinic leadership of a wide range of clinical services including adult clinical services, the Dialectical Therapy Program, and the Assertive Community Treatment Team. Along with the Medical Director, he oversees all aspects of intake, clinical programming and program development.  He holds a Master of Arts degree in clinical psychology from Antioch New England Graduate School.


Region 2: Maryann Evers, LICSW is the Director of Family Support and Home Visiting at Child and Family Services. She has held clinical programmatic administrative positions in outpatient mental health and child welfare for over 30 years.  Her  expertise includes working with clients' experiencing substance use disorder and early childhood mental health. She has participated in multiple interdisciplinary projects focused on improving health outcomes for families and children. Maryann has a Master of Social Work degree in Reflective Practice from BU and is certified as an Early Childhood Mental Health clinician.


Region 3:  Marie Macedonia, MS, PsyD is the Integrated Dual Disorder Treatment Team Coordinator at Greater Nashua Mental Health Center where she provides high level of care to individuals with serious and persistent mental illness and severe substance use. Since 2015, she has worked with individuals suffering from co-occurring disorders. She began working with adolescents struggling with substance related disorders during her pre-doctoral internship. Dr. Macedonia has a doctoral degree in Psychology from Antioch University New England.


Region 7:  Annette Carbonneau is the Program Manager at the North Country Health Consortium where she is responsible for oversight and development of the Ways2Wellness Community Health Worker Program. This program is based on researched and evidence- based practices around the country. Annette has 14 years of non-profit experience managing projects that provide family, provider and community education.