The BeST Center, Cleveland Clinic Lutheran Hospital psychiatry units and six community mental health agencies, The Centers for Families and Children, Connections Health*Wellness*Advocacy, Murtis Taylor Human Services System, Psychological and Behavioral Consultants, Recovery Resources and Signature Health, offer a Loved Ones Involved in a Network of Care (LINC) program. The LINC program focuses on proactive family psychoeducation and continuity of care as patients transition from the hospital to community-based care. LINC is centered on guiding patients and families through a LINC manual focused on mental illness education, communication and problem-solving. Hospital and community-based clinicians are trained as LINC consultants. Patients and families are introduced to LINC while the patient is in the hospital, and those who wish to participate in LINC engage with a community-based LINC consultant upon discharge.
LINC expedites psychiatric inpatient discharge planning and scheduling outpatient appointments within the two weeks required by Ohio law. In the past, hospital-based discharge planners have often had to make multiple attempts to schedule outpatient appointments. Partner agencies make time in their weekly schedules for LINC consultants and psychiatrists to see LINC patients who have recently been discharged from the hospital and their families. Discharge plans reflect that patients and families have been introduced to LINC, that they wish to engage in LINC services and that they have established goals for outpatient treatment. The LINC program also helps agencies to retain patients in treatment and to engage families as part of the recovery team.
Research has shown that family-based services significantly reduce patients' relapse and re-hospitalization rates and help families to cope more effectively with their loved ones' illness. LINC provides vital mental illness education and helps patients and families develop lifelong communication and problem-solving skills. LINC also promotes seamless continuity of care by expediting community-based appointments and allowing patients and families to continue with the LINC program that they were introduced to while the patient was hospitalized as part of community-based treatment.
Research shows that patients who do not keep initial outpatient appointments following hospitalization are twice as likely to be re-hospitalized within the same year, compared to those who keep at least one follow-up appointment. The overall costs of care for patients who attend initial outpatient appointments and follow treatment recommendations is decreased due to fewer re-hospitalizations and/or shorter durations of stays if re-hospitalization is required. A strong family support system is one of the factors that predicts following recommended treatment, including attending an initial outpatient appointment.
LINC provides patients and families with practical, immediate help and support when they need it most: during crisis/hospitalization and the critical transition from inpatient to outpatient treatment. Opportunities for patients and families to be introduced to LINC while the patient is still in the hospital and to engage in LINC illness education and communication and problem-solving skill-building in outpatient settings and close coordination between hospital and community LINC consultants make the program innovative and unique.
The BeST Center created the LINC program model, adapted the LINC manual and developed the implementation strategy. The BeST Center provides expert training, consultation and technical assistance with all aspects of the LINC program, including helping to recruit and engage hosptial and agency partners, patients and families. The BeST Center will facilitate a LINC learning collaborative and provide regular opportunities for LINC consultants to learn from, by and with each other. The BeST Center also plans to produce a newsletter specifically designed to enhance LINC consultants' knowledge and skills.
The BeST Center provides LINC manuals for consultants, patients and families and the services of half-time managing consultant/trainer with expertise in implementing LINC services for up to one year. The consultant/trainer is embedded at the hospital and works directly with hospital and community-based staff to ensure successful overall program implementation. The BeST Center's managing consultant/training is also developing a hospital-based "LINC champion" to coordinate the program after she leaves to begin a LINC program in another community. The LINC champion will use a train-the-trainer model to develop inpatient and outpatient LINC consultants.
The LINC program can be effectively replicated to serve patients and families in other communities. The BeST Center can provide time-limited training, consultation and technical assistance from an embedded expert, LINC manuals and other materials to facilitate replication of the program. The BeST Center plans to expand its services to additional hospital sites in Cleveland and to establish LINC programs in other parts of Ohio.
Each agency partner will develop specific, previously agreed-upon measures to evaluate the LINC program, including the percentage of appointments scheduled within two weeks following hospital discharge, the number of patients and families who attend outpatient appointments, how many appointments they attend and the percentage of patients who are re-hospitalized within a one-year period following participation in LINC.