Hospital-led Community Collaboration Improves Behavioral Health Care

A collaborative network of hospitals and community organizations is improving behavioral health care in Connecticut. Norwalk Hospital partnered with community stakeholders to establish the Greater Norwalk Community Care Team, focusing on delivering enhanced care to individuals with complex medical and psychosocial challenges. About 15 representatives from participating organizations meet weekly to discuss 12 to 17 “clients” or cases. During meetings, CCT members also analyze utilization data, including demographics and diagnoses; frequency of ED visits; housing placement; and connection to medical, psychiatric, substance abuse and case management services. A CCT navigator facilitates meetings, keeping notes of patients' individual treatment plans and coordinating work to ensure follow-up. The navigator also monitors ED utilization on a monthly basis, with near real-time results to track program effectiveness. From spring 2014 to fall 2015, the Greater Norwalk CCT developed care plans for 177 individuals. Outcomes for patients with care plans include mental health stabilization, maintained sobriety, and a reduction in inappropriate ED visits by nearly 27 percent.

For more information, contact Katherine Michael, M.D., medical director, community health, Western Connecticut Health Network, at katherine.michael@wchn.org or Joyce Bretherton, communications manager and community health program manager, Norwalk Hospital and Western Connecticut Health Network, at joyce.bretherton@wchn.org. A complete case study is included in the HPOE guide “Triple Aim Strategies to Improve Behavioral Health Care” at http://www.hpoe.org/tripleaimbehavioral