The Best Practices in Schizophrenia Treatment (BeST) Center is designing a pilot Continuity of Care Family Services program, a seamless system of care centered on proactive family education and support and close care coordination that will potentially lead to fewer psychiatric re-hospitalizations and improved quality of life for patients and their families. The BeST Center is collaborating with the Cleveland Clinic Lutheran Hospital inpatient psychiatry unit and six community-based mental health providers to implement the pilot program.
A BeST Center consultant will train hospital social work staff, interns and community clinicians in Consumer Centered Family Consultation (CCFC), a brief intervention developed from evidence-based Behavioral Family Therapy. A trained clinician will guide patients and families through a CCFC manual focusing on mental illness education and communication and problem-solving skill building. Hospital staff will conduct initial CCFC sessions with interested patients and families. Follow-up appointments will be scheduled with community-based CCFC clinicians, allowing patients and families to continue CCFC in outpatient settings. Participating agencies will reserve weekly times for CCFC-trained clinicians and psychiatrists to see patients recently discharged from the hospital. Inpatient notes related to CCFC will be included in patients’ electronic medical records. Discharge plans will be shared with outpatient providers.
The BeST Center Continuity of Care Family Services program is being designed to provide patients and families with practical, immediate help and support when they need it most: during crisis/hospitalization and during the critical transition between inpatient and outpatient treatment. Research shows that individuals who do not keep initial outpatient appointments following discharge from an inpatient psychiatric stay are twice as likely to be re-hospitalized within the same year, as compared to those who keep at least one follow-up appointment. A stronger family support system is one of the factors that predicts following recommended treatment, including attending a first outpatient appointment. Opportunities for patients and families to engage in CCFC in both inpatient and outpatient settings and close coordination among hospital and community providers make this program innovative and unique.
The BeST Center will facilitate a Continuity of Care Family Services learning collaborative and provide regular opportunities for hospital staff and community providers to exchange information about implementation, service provision and sustainability of the program. As new programs are implemented with additional partners in other regions, these providers will be invited to participate in the Continuity of Care Family Services learning collaborative.
The BeST Center will provide CCFC manuals for clinicians, patients and families participating in its Continuity of Care Family Services program and up to 50 percent of a consultant/trainer with family services expertise’s time for one year. The consultant/trainer will be embedded at Lutheran Hospital and in community partner agencies to ensure successful implementation and sustainability. The BeST Center is fostering relationships with and among the hospital and the agencies participating in its pilot program with an overall focus on continuity of care for patients and families. This program will make it easier for hospital social workers to schedule follow-up appointments with community providers within the two weeks required by Ohio law; currently, they make multiple attempts to schedule follow-up appointments with community providers. This program will also help agencies to retain patients in treatment and to engage families as part of the recovery team.
The BeST Center believes that, with the right leadership and commitment from other hospitals and agencies, its Continuity of Care Family Services program could be easily replicated for psychiatric patients and their family members/support persons in other communities. The BeST Center can provide time-limited training, consultation and technical assistance, CCFC manuals and other supports to partners who wish to provide seamless continuity of care and proactive family education and support by implementing the BeST Center Continuity of Care Family Services program. The BeST Center’s goal is to expand the program to Northwest Ohio next year.
Each agency partner will develop specific, previously agreed-upon measures to evaluate the BeST Center Continuity of Care Family Services program, including the percentage of appointments scheduled within two weeks following hospital discharge, the number of patients and families who attend outpatient appointments and how many appointments they attend and the percentage of patients who are re-hospitalized within a one-year period.