As some behavioral health leaders focus on “whole-body” treatment — with an emphasis on behavioral health and physical health coordination — there remains fragmentation across the care continuum.
A new patient triage model from Birmingham, Ala.-based Pathway Healthcare and Watershed Health aims to ease the transition from hospitalization and emergency services to outpatient care, Stephen Taylor, MD, chief medical officer of Pathway Healthcare, told Becker’s.
Pathway offers behavioral health and substance use disorder care through therapy, psychiatry and medication management across Alabama, Mississippi, Tennessee and Texas. Watershed Health is a care coordination platform that helps manage the post-acute care process.
The model transitions individuals from an inpatient setting — whether they have received mental healthcare or substance use disorder care — to outpatient services, including connecting them to a therapist through telehealth. Therapists conduct initial virtual meetings to offer a warm welcome and help patients transition into various levels of outpatient care.
Many individuals hesitate to seek mental health or substance use disorder treatment because the treatment system itself has historically been unwelcoming, judgmental and not patient centered, Dr. Taylor said.
“What this does is make a tremendous improvement in the likelihood that that person — once they’re discharged — is going to follow up,” he said. “Because now they’ve made a connection to an individual. They’ve seen a face, they’ve seen a person. That person is welcoming. It’s just a whole lot less anxiety provoking to think of having left that inpatient setting to now go to this other place to get treatment.”
The period immediately following hospital discharge is a critical window for connecting patients with continued care, Dr. Taylor said. Traditional follow-up methods — such as providing patients with contact information on a slip of paper — can further contribute to fragmented care.
“By doing this warm handoff, we communicate with the patient in a very real way, without necessarily saying it, but instead with them simply experiencing it,” Dr. Taylor said. “’We welcome you with open arms. We are here for you. We don’t judge you. We don’t look down on you.’”
Privacy and confidentiality of patients’ data are top priorities, he said. When Pathway makes contact with outpatient or inpatient providers to hand off patients, it obtains informed consent from them. This streamlines communication and referral processes, enabling a smoother transition to other treatment settings, Dr. Taylor said.
Clinicians will also be trained on the evidence-based American Society of Addiction Medicine Criteria — a set of standards for placement, continued service and transfer of patients with addiction and co-occurring conditions.
“This gives us yet another opportunity to help people understand you have an illness,” Dr. Taylor said. “This is a chronic medical illness and we want to provide the kind of care that makes sense. That does not involve judgment or stigma or shame and gives you ongoing treatment for what we know is a chronic condition.”
