Care Coordination at Work: Steve and Roxanne

Steve and Ralph pose at a table where they met to reunite over coffee at a Tim Horton's.

A Care Coordinator’s job is to connect and refer people to the services and supports they want and need, connecting the dots in all aspects of care. But in many cases, Care Coordinators do so much more.

One such story involves a man who just wanted to track down his brother, and a Care Coordinator who knows him very well.

Steve and Ralph pose at a table where they met to reunite over coffee at a Tim Horton's.

Steve (left) and his younger brother Ralph (right) recently reconnected after nearly 20 years thanks to some help from Steve’s Care Coordinator, Roxanne. Ralph surprised Steve by bringing him a photo of them as kids with their two other brothers.

So, when Steve Jenney and Roxanne Monteleone patiently waited inside a coffee shop, Steve wasn’t nervous. He had Roxanne, his Person Centered Services Care Coordinator, there with him just in case he needed her.

The two waited until a blue truck pulled up. That’s when Steve saw Ralph.

The reunion between the two brothers was made possible thanks to Roxanne’s hard work and newfound investigative skills.

Roxanne has known Steve for over 20 years, since she met him while working at the adult care facility where he previously resided.

She knew that Steve lost contact with his brothers quite a while ago and didn’t have any family in his life for a very long time.

Steve, who has been on his own for most of his life, told Roxanne that all he wanted to do was find members of his family. Roxanne made the search her priority.

“I had always wanted to find (my brothers) because I’m the type of person who likes to connect with people,” said Steve.

After some Google searching, Roxanne tracked down two of Steve’s brothers. Unfortunately, she had to deliver the tough news that his brothers Howard and Kenny had passed away. It was then that Steve mentioned Ralph, his third brother.

“Believe it or not, me and my brother Ralph spent more time together than any of the other brothers,” said Steve.

Roxanne again took to Google to search for Ralph and discovered he was living in a town nearby.

“With Steve’s permission I sent Ralph a letter, and I swear (Ralph) must’ve called me the day he got it,” Roxanne said. “Steve wanted me present for the reunion.”

She felt honored when Steve asked her to be there for the reunion with his brother. Knowing all that he’s been through over the years she also felt a sense of protection over Steve, so she was also glad she could be there to look out for him.

“I wanted to feel out the situation,” said Roxanne. “Steve and I have a long history of working together, and I just wanted to make sure he was ok.”

The reunion couldn’t have gone any better. Ralph and Steve shared stories of their childhood and Roxanne even learned that they had two more brothers, both of whom passed away when they were younger. Steve is the second oldest of the six boys.

“My favorite part about working with Roxanne is we understand each other,” Steve said.

As his Care Coordinator, Roxanne has been there for Steve through a lot of major life changes beyond helping him reconnect with his brother.

Roxanne helped Steve through the process of moving out of a group home and into his own apartment, a goal of his that he expressed during a personal outcome measures (POMs) interview.

“This was a big step because all he’s known has been living in places that have staff around the clock,” says Roxanne. “I admire Steve for all that he’s been through, and I like the fact that he advocated for himself to finally leave the group home.”

They looked at various apartments, and when they found a good fit for Steve in a secure building he finally moved out.

“I’ve been in my place for about four years already,” Steve said.

Roxanne did have some concerns about Steve moving out and still does today, especially as he gets older, but she understands that he has a right to live the life he wants to.

“[Steve] taught me a lot about dignity of risk,” said Roxanne. “He has a right. He can speak up for himself. I’ve asked him about moving into a more supported apartment but he’s adamant that he absolutely does not want to.”

She and Steve are now in the process of working together to get him the supports he needs to continue living in his apartment on his own, including community habilitation and visits from a nurse, which brings its own new challenges.

“What Steve has taught me goes back to making sure (people) can live the life they want to live, Roxanne said. “Just making sure that they can live that life by finding the supports. It’s been a struggle. It’s been frustrating, but he’s happy.”

Roxanne continues to put Steve’s safety and overall well-being at the forefront of her work, but always remembers to keep his wants and goals in mind.

“It’s sitting back and not just hearing the person, but actually listening to them,” says Roxanne. “You just have to listen and work with that person, not go in there thinking that you know what’s better for them. I struggled with [Steve] moving, but I’ve known Steve for years and he’s happy, and that’s what it should be about.”