Transition Team Bridge Inpatient to Outpatient Mental Health Services for Complex Mentally Ill

In my previous “Walkabout Medical Home” blog posts I have highlighted the work Primary Health Care Organizations (PHCOs) in Australia (Medicare Locals) have done to connect people with mild to moderate mental health diagnoses to primary care or community-based services. This blog highlights the innovative work being done stateside by Oregon’s Health Share.

Health Share is one of the state’s 16 Coordinated Care Organizations (CCO) targeting patients with complex mental illnesses. The CCO utilizes the Intensive Transition Team (ITT), which is designed to address a gap in the care system and provide services to those hospitalized with mental illnesses that are faced with a discharge but have had no prior or inadequate connection with a community mental health provider. For example, patients undergoing their first psychotic break who have not established relationships with the mental health system or patients with long-term disabilities that have ‘given up’ on the mental health system due to multiple environmental and psychosocial reasons.

With funding from the federal Centers for Medicare and Medicaid Innovation, the ITT were launched in three parts of Health Share’s catchment representing diverse geographic areas ranging from urban Portland to rural Clackamas County. This required that the model be adapted in each region to develop appropriate care pathways from hospital to outpatient mental health services reflecting available community resources such as peer, housing, and social services.

Getting referrals for the ITT from the hospitals took some ramping up. After using a media campaign to disseminate information, as well as visiting many of the inpatient psychiatric units to explain the program, referrals have grown to a point where it is often challenging to take on more.

Referrals are typically made either by hospital social workers or the CCO’s care coordinators. Eligible patients must be willing to be involved in intensive, short-term therapy and have no current involvement in outpatient mental health services. The ITT begins by visiting the patient while in the hospital—a key strategy for establishing the relationship. Post-discharge, the team follows the patients for 30-45 days connecting them to a community-based mental health provider, sometimes accompanying the patient on the first couple of visits, as well as a range of transitional support services.

HealthShare’s ITT clinicians are:

  • Patient-centered and skilled case managers
  • Based at county crisis centers placing them in a vantage point to intervene if the patient begins to destabilize post discharge
  • Masters prepared and trained in motivational interviewing
  • Experts at understanding available community resources
  • Team members working with peer support staff and medical providers

The ITT has not only increased access to critical services for some of the most vulnerable members of the community, but has established new care pathways improving coordination between providers and leveraging existing services.

australian-artAustralia Outback: Roadside Art

I’ve heard about the Australian outback, but on a recent trip to the Northern Territory I got a snapshot of how rugged and remote most of Australia is. One thing I didn’t expect was the unique ‘roadside art’ that occupies the hundreds of miles between Alice Springs known as the country’s “Red Center” and Darwin also know as the “Top End”. Aussies have added their creative flair to many of the countless termite mounds that line the Stuart Highway offering motorists an outdoor gallery that is quite entertaining and uniquely Australian!

This represents my last “Walkabout Medical Home” blog from Australia. I’m back at our NASHP Portland, Maine office on July 1 where you can reach me at G’day mates!