PeaceHealth Oregon West Network – Transition Team

Overview

PeaceHealth is a family of hospitals, clinics, and doctors, based in the Pacific Northwest. This network of faith-based, mission-oriented facilities has grown to include services throughout Oregon, Washington and Alaska. PeaceHealth Oregon West Network is one of four networks offering a broad spectrum of medical care. This network has three medical centers in Eugene, Springfield and Cottage Grove, and a critical access hospital in Florence. In addition, there are 12 primary and specialty care clinics as well as outpatient laboratory facilities in each municipality. Oregon West Network has become a leader of health care delivery services in Oregon, especially in the delivery of behavioral health services for those residents who are most vulnerable.

PeaceHealth Behavioral Health Services (BHS) is composed of a continuum of care that provides a range of services, including inpatient psychiatric care, partial hospitalization, transition services, telemental health, crisis services, outpatient psychiatry and counseling, research projects, primary care integration, young adult and first-episode psychosis-specific treatments.

In spring 2004, PeaceHealth BHS formed the Transition Team in collaboration with Lane County Behavioral Health Services. The program provides intensive supports to individuals who are medically indigent or very low income immediately following psychiatric hospitalization or psychiatric emergency department visit. The program provides intensive case management, therapy and community supports, including assistance establishing income through employment or public benefits and stable housing. Since summer 2004, the program has offered a home-cooked hot meal free of charge every Wednesday, bringing together current clients with program graduates and staff members for a “community lunch.” After the lunch, the team hosts group outings in the community from bowling to museum tours to trips to the local rose garden. The program provides full holiday events including holiday meals with all the fixings, decorations, gifts and games.

The Transition Team also maintains a fully stocked “clothes closet” complete with clothes in all sizes, toiletries and household items. While most items are gently used donations, the “dignity project” supplies new undergarments and toiletries to anyone in need. In addition, a volunteer refurbishes bicycles that are donated to clients, along with helmets and bike locks.

Impact

At any given time, the Transition Team serves approximately 100 active clients. The readmission rate for patients served by the team is extremely low, averaging 0 to 2 per quarter for admission within 30 days of discharge, as compared with 24 percent for the inpatient behavioral health unit as a whole.

Lessons Learned

Program leaders learned the value of building community and that informal supports are often more effective in improving quality of life than formal therapy interventions. When clients talk about how this program has literally saved their lives, they reference the support they receive from the community lunch and the relationships they have built.

Future Goals

Plans include establishing transition housing for patients who are homeless. The local community mental health agency had previously funded eight transitional apartments; however, funding was lost in 2014. PeaceHealth BHS hopes to offer this essential support as a bridge to permanent housing.

Contact: Mary Anne McMurren
Vice President, Post-Acute Services
Telephone: 541-338-1656
Email: mmcmurren@peacehealth.org