Behavioral Health
Inpatient Psychiatric Facility Collaborative Newsletter
June 2018

Recommendations for Care Transition Support (Part III)

Patients who have support as they transition from hospitalization to outpatient services are more successful at remaining stable in the community and avoiding a readmission. In our previous newsletters, we shared recommendations for providing care transition support. This month, we look at other community support strategies that can help ensure patients' success upon discharge from the hospital.
Strategies for Care Transition Support:
  • Care Transitions Intervention®. This intervention developed by Dr. Eric Coleman and his team at the University of Colorado uses a coach to support the patient through their transition. The coach focuses on helping the patient and family caregiver develop skills and confidence to assert their treatment preferences and ensure that their needs are being met during transitions.  It is recommended that the coach have a mental health background when providing coaching for a person diagnosed with a mental health illness.
  (Coleman, 2006)
  • Case or care managers have a series of regular follow-up communications with the patient to ensure that medications, meals/nutrition, transportation, appointments and other needs for the patient are in place.
  • Consider an Assertive Community Treatment (ACT) intervention, a service-delivery model that provides comprehensive, locally-based treatment to people with serious and persistent mental illnesses. Unlike other community-based programs, ACT is not a linkage or brokerage case-management program that connects individuals to mental health, housing, or rehabilitation agencies or services. Rather, it provides highly individualized services directly to patients. ACT recipients receive the multidisciplinary, round-the-clock staffing of a psychiatric unit, but within the comfort of their own home and community. To have the competencies and skills to meet a client's multiple treatment, rehabilitation, and support needs, ACT team members are trained in the areas of psychiatry, social work, nursing, substance abuse, and vocational rehabilitation. The ACT team provides these necessary services 24 hours a day, seven days a week, 365 days a year.
North Carolina :          
  • Critical Time Intervention (CTI) is an empirically supported, time-limited case management model designed to prevent homelessness and other adverse outcomes in people with mental illnesses following discharge from hospitals, shelters, prisons and other institutions.
  • Project RED (Re-Engineered Discharge) An evidence-based intervention that is a patient-centered, standardized approach to discharge planning and discharge education.
News and Happenings
IPF Surveys:
If you have not already done so, please take a moment to complete the survey that was emailed to you. It takes less than five minutes to complete. The information you provide will be especially helpful for planning the next steps in our readmission reduction work.
Onsite Visits:
The IPF onsite visits are underway. It has been exciting to learn about new interventions that have been implemented since the initial onsite visits last Spring, get updates on your quality improvement projects, and explore how we can help you understand and use your readmission measure dry run report to improve care transition processes. If you have not scheduled your visit, please contact Melanie to set a date.

This material was prepared by GMCF for Alliant Quality, the Medicare Quality Improvement Organization for Georgia and North Carolina, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
Publication No. 11SOW-GMCFQIN-G1-18-37