May is Mental Health Awareness Month in the US. To honor this incredibly important topic, today we’re highlighting five innovative organizations across the country that have found effective ways to coordinate care and improve outcomes for some of our nation’s most vulnerable populations.
One of the biggest challenges for treating patients with mental or behavioral health conditions is that any single point of care is often not enough to provide the support needed. As a result, patients may move between primary care providers, emergency departments (EDs), and behavioral health specialists to receive the treatment they need. By connecting the fragmented care together through the use of technology, care teams can work together to support these individuals.
Navos Mental Health Solutions specializes in helping patients suffering from mental illnesses and substance use disorders through a variety of different care settings. Navos staff found it challenging to track these patients and gain needed insight such as medical records, lab results, and medications. To address this, Navos took an integrated approach using real-time technology that could notify case managers and social workers of patient encounters across the care continuum. Using this information allowed staff to prioritize follow-up efforts, resulting in a 15 percent increase in seven-day follow-up rates.
Aspire Health Alliance partners with organizations and clinics throughout Massachusetts to provide better care to MassHealth (the Massachusetts Medicaid system) patients struggling with behavioral health conditions. Aspire created Behavioral Health Community Partner programs to provide the additional support and resources that vulnerable patients need. Using real-time visibility, Aspire staff can connect patients to physicians or social workers that can work with them outside of costly ED visits. By connecting with patients during crisis encounters, Aspire has been able to increase opt-in patient engagement rates by 150 percent.
Community Based Coordination Solutions (CBCS) works to coordinate care for complex patients, many of which are homeless, struggle with substance use disorder, or are affected by social determinants of health. CBCS implemented real-time technology to enable case managers to intervene when a patient needs help the most—instead of days or weeks later. Care plans are created collaboratively by case managers, ED physicians, primary care and speciality providers, social workers, and pharmacists. These guidelines are then stored within a platform that can be easily accessed by everyone involved in the patient’s care, ensuring that they receive continuity of care regardless of where they are. This visibility has allowed CBCS patients to experience, on average, a 50-60 percent reduction in ED utilization.
Mid-Valley Behavioral Care Network, located in Salem, Oregon, was struggling to efficiently coordinate patient care. Staff were waiting for faxes, making phone calls to different hospitals, and hoping that patients would provide information like discharge paperwork. Knowing there had to be a better way, Mid-Valley turned to technology, hoping to alleviate some of the administrative burden that was taking away from patient care. Implementing real-time notifications has allowed Mid-Valley case managers to be proactive in prioritizing follow-up calls and spend more time engaging with patients—with seven-day follow-up rates increasing by nearly 11 percent.
Sturdy Memorial Hospital, a small, independent hospital in southeast Massachusetts, was struggling to find beds and funding to take care of patients with behavioral health needs, leading to ED boarding of behavioral health patients.
To address this problem, Sturdy Memorial teamed up with a behavioral health clinical group to help identify patients and assign them to outpatient programs with a dedicated case manager. All of this information was then stored within a care collaboration platform that would automatically notify both ED physicians and case managers when a patient presented at the ED—allowing for a seamless transition of care. By diverting care to non-acute settings, Sturdy Memorial has been able to see a 78 percent decrease in ED utilization by enrolled patients.
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