The patients who discharge coordinator Diane Williams sees coming to Genesis Detox in Brooklyn, New York, face complex health conditions that sometimes have relatively straight-forward solutions. People arrive with complex and chronic health care needs, often intertwined with critical daily living needs such as a lack of access to food, a place to sleep at night and employment.
“They just say ‘support’ for their journey,” Williams says. That support starts at Genesis and continues long after a patient is discharged following an emergency event. Genesis partners with VNS Health to develop individualized post-acute care plans that help ensure safer and more seamless transitions back home and into the community, especially for those diagnosed with co-morbid health conditions.
“Integrated, multidisciplinary care is an essential element of supporting individuals with chronic, complex mental health and substance use conditions in the long-term,” says Jessica Fear, SVP of Behavioral Health at VNS Health. “Our goal is to break the cycle of emergency admissions and readmissions. Thanks to our strong relationships with referring providers, we can ensure that each person receives the appropriate level of care, based on their individual needs and unique situation. We focus on addressing obstacles standing in the way of recovery, and by giving people the appropriate support when and where they need it, to stay out of crisis.”
In short, an integrated post-acute program for behavioral health addresses the most serious challenges and interruptions in care, ones that can often hinder progress for people with complex and co-morbid, chronic mental health and substance use conditions. They help providers:
- Treat the whole person, with a focus on patients’ overall physical and behavioral health,
- Lower the cost of care for patients with chronic and complex mental health and substance use diagnoses
- Address social determinants of health that can negatively impact recovery
And they do so with attention on the three levels of post-acute care.
How a “meet them where they are” strategy works for patients with complex behavioral health needs
VNS Health has built its integrated behavioral health care model as a roadmap for post-acute transitional care. Beginning with a pre-discharge assessment, each level of care assignment increases in intensity and duration, depending on where individuals are in their recovery journey.
Level 1: Behavioral Health Community Transitions
Level 1 is designed to transition patients back to their community following discharge from either an emergency department (ED) or an inpatient unit for psychiatric or substance use. This includes services like scheduling and attending crucial 7-day and 30-day post-discharge visits, managing medications, and making connections to additional outpatient resources.
Level 2: Community Transitions with Care Management
Some overlapping behavioral health and chronic medical conditions require more substantial, longer-term support. Individuals stay in this care management level for three to six months, with an emphasis on improving overall health outcomes and reducing their reliance on emergency services.
During this time, additional assistance is arranged to address immediate social determinants of health — such as access to food and housing — and connections to mental health and substance use treatment providers within the community.
Level 3: Intensive Care Management and Treatment
Level 3 is the most intensive post-acute care program, extending up to nine months to provide expanded multidisciplinary care for the most challenging mental health and substance use disorder diagnoses. VNS Health’s team — credentialed care managers, licensed social workers, psychiatric nurse practitioners and substance use counselors — works in lockstep to implement more advanced, long-term care and risk avoidance strategies.
Additional high-touch support includes resources for food and housing, personal escorts to and from treatment appointments, medication reconciliation and connections to trusted peer and community-based recovery programs.
“[VNS Health] are consistent, respectful, and clearly helping people,” Williams says. “I believe that if a patient is ready to make changes in their life, then VNS Health can assist them with every need that they have.”
This Views article is sponsored by VNS Health. To learn more about how VNS Health helps health plans and care providers manage complex behavioral health populations, download this free VNS Health – BHB white paper.