Transition of Care
Member:
When a member goes into a mental health hospital, a new staff member is added to the member’s care team for a short time. This will give the member more time with a care team member. The member will have more visits and more phone calls with the care team. The new team member will complete a series of questions with the member at the first face to face visit. The team member will use the answers to help the member find ways to make changes in day to day life. Some changes may be: school, food, money, bills, job, exercise, hobbies, or anything that may make life easier, and cause less need for hospital stays.
Providers:
Purpose:
To identify and address barriers to improve quality of life and lower the frequency of crisis intervention services such as hospital and emergency room visits. To assist in locating less restrictive placement for members, whether it be housing with Supportive Living Services provider or a home with wrap around services.
When a member is admitted to a mental health facility, a secondary Care coordinator will be added temporarily to member’s Care Coordination team.
The additional services provided will be:
- Bi-weekly face to face visits
- Additional phone calls
- Safety plan review and update
- Social Determinants of Health Assessment
- Locate and assist to implement resources to address Social Determinants of Health barriers
Barriers that may be identified and addressed:
- Education- GED, continuing education, hobbies or skills trainings
- Employment/ Underemployment- resume resources, job search and application
- Food Insecurity- food banks, SNAP
- School- classroom accommodations, IEP
- Exercise-sports, gym, in bed workouts
- Hobbies- joining common interest groups, practicing hobbies, accessing supplies
- Support Groups- engaging with people with similar barriers
- Or any other barriers that may be identified.