Behavioral Health

Increase collaboration among behavioral health, hospital, primary care, and other care locations to improve the quality and safety of clients’ care interactions and experiences

Assist hospital and primary care nurse care managers through reviews of clients’ emergency department/hospital discharge plans and in making further treatment recommendations as needed

Assess the accuracy of SMI versus medical diagnoses by ensuring clients are receiving the right diagnoses in order to receive the right treatments

Proactively identify clients’ warning signs and assess risk for re-admissions through the use of a shared longitudinal health record

Coach clients in avoiding unnecessary emergency department utilization by educating them on the appropriate use of behavioral health and primary care services when warning signs and risks are presented

Facilitate patients’ transitions to primary care, behavioral health, or emergency department settings depending on the severity of their ailment(s) or if follow-up care is needed

Review post-acute care plans within 24 hours of emergency department or hospital admission notifications

Provide same-day services on date of discharge from the emergency department or hospital following notifications

Schedule follow-up medical appointments with PCP

Review medication lists and discharge instructions with clients to ensure they are informed of their role in the plan of care

Communicate plans of care with the medical home Advocate for resources and follow-up care for marginalized clients

Ensure that duplicate laboratory tests and/or radiology reports are not ordered by reviewing clients’ comprehensive electronic health records

Advocate for clients when additional care is needed from another provider or specialist

Look for gaps in care to ensure clients’ activities are aligned across various healthcare settings

Reduce clients’ needs for unnecessary documentation for reimbursement purposes

Confirm correct medication lists during transitions of care by reviewing filled/dispensed medications (over last 120 days)

Prevent duplication of medications after discharge to avoid overprescribing, eliminating redundancies and extra costs

Monitor medications to prevent misuse and risk of harm

Identify potentially adverse drug combinations/interactions and/or dosing levels

Teach high-utilizing clients about the appropriate use of care settings beyond the emergency department

Help clients use their data to get better outcomes, make better decisions, and take greater ownership of their care

Coach clients on self-management of chronic diseases, with referrals to appropriate resources as needed

Intervene with clients following their medical events to help them recollect the events and debrief on their causes, clarify reasons for medical interventions, and ensure compliance with treatments