By: Sheila Peck, LICSW & Heather Ross, LICSW
In April 2023, C3 launched its groundbreaking Behavioral Health Transitions of Care (BH TOC) program to transform the landscape of mental health care. Designed to reduce psychiatric readmissions for our members, our BH TOC program employs a comprehensive approach to address the complex needs of individuals in the behavioral health community. It is staffed by Social Workers (SWs) onsite at psychiatric facilities and Community Health Workers (CHWs) working in the community, forming a dynamic team to support patients for up to 60 days after being discharged from the hospital.
The program is located at three high-impact inpatient psychiatric hospitals: Bournewood Hospital, HRI Hospital, and Arbour Hospital. This partnership allows us to deliver enhanced patient care, where we collaborate with inpatient staff, coordinate discharge plans, share pertinent clinical information and progress updates, and ensure a smooth transition from the hospital to the community. This ongoing collaboration is essential in our effort to provide an exceptional level of care to those in need of mental health care.
Our goal this year is to expand this program to additional facilities, with the emphasis placed on fostering collaborative relationships that best serve the behavioral health needs of our members.
What kind of care are members receiving as a result of their participation in BH TOC?
- Enhanced Engagement in Treatment: The program assures members are engaged in their treatment by ensuring timely follow-up appointments, strengthening connections to community-based services, reducing barriers to accessing care, and improving communication between behavioral health providers and medical providers. Patients are taught about their conditions and treatment options.
- Reduced Readmissions to Psychiatric Facilities: The goal is to reduce the number of psychiatric readmissions by streamlining the discharge planning process. In addition to clinical consultation, BH TOC staff assist with aftercare referrals and scheduling, offering transitional support during the critical post-discharge period and engaging patients proactively in crisis intervention. With this transitional outpatient support, patients have support to prevent readmission to the inpatient setting for care.
- Care Coordination: The program seeks to improve patient outcomes by advocating for timely, comprehensive, and patient-centered care, by facilitating collaboration among the patients’ entire outpatient care teams, and by evaluating the efficacy of patients’ treatment plans, and adjusting them as clinically appropriate.
The BH TOC program is an innovation in mental health care because it aims to make lasting improvements for individuals by addressing not only their clinical needs but also their non-medical needs, such as housing, food security, transportation, economic stability, and more.
The BH TOC program is built to serve as a catalyst for positive change in mental health care.
What our FQHCs are saying:
“Patient engagement has improved with the bridge from the BH TOC to New Bedford Community Health’s (NBCH) BH services. Patients feel heard and supported by having a clear plan at discharge. Patients are showing up to the appointments and want to engage in BH care.
BH Clinicians finding out ahead of time a patient will need prescriptions has been a big benefit to our patients. We have been able to bridge meds until their psych appointment. The positive outcome of NBCH staff working with C3 BH TOC has had a positive impact on our Behavioral Health Clinicians; having contacts for discharge planning supports the BHC and the patient is not lost in the loop of discharge planning.”
–Integrated Behavioral Health at New Bedford Community Health
“Kennedy Community Health’s (KCH) collaboration in the BH TOC program has been an extremely positive experience! Prior to the collaboration, we were experiencing great difficulty with communication in the psychiatric units due to several reasons. This led to a struggle when patients were being discharged home. Since starting the program, we have seen an improvement in both forming connections with the hospital, as well as patient engagement once discharged from the facility. Patients have been able to form a relationship with BH TOC staff prior to being discharged. Once discharged, they are seamlessly handed off to a familiar case manager at KCH with all the appropriate follow-ups booked ahead of time. In my opinion, this has set the patients up for better success. This program has made continuity of care much more achievable and significantly aids in maximizing patients’ positive outcomes.”
—Kennedy Community Health, Transition of Care Team
C3’s Behavioral Health Transitions of Care program is committed to reducing readmissions and enhancing patients’ overall care through our innovative approaches and collaborative efforts. By concentrating on high impact psychiatric units and eyeing expansion to more units down the road, BH TOC is poised to continue its transformative impact on the behavioral health landscape.
Stay tuned for more updates on our progress and forthcoming developments in the near future!
