Scattergood Foundation

Advancing Innovative Strategies for Change in Behavioral Health

Family Services, Inc.

Name of Innovative Program: 
CareLink Transitions
Sponsoring Organization
Family Services, Inc.
Name of Innovative Program Lead: 
Carrie Zilcoski
E-mail Address of Innovative Program Lead:
Physical Address of Innovative Program: 
610 E. Diamond Ave, Suite 100
Project Description: 

CareLink Transitions is an innovative program designed to provide free case management services to behavioral health patients who use the Emergency Department as their primary means of obtaining healthcare. Family Services, Inc. has successfully implemented this program at four local hospitals and has reduced Emergency Department recidivism by 84% in behavioral health patients.  Case management services include: meeting with the patient upon discharge to begin a relationship and follow him/her for 30 days, home visits by licensed nurses/case managers to assist the patient to remain safely in the community, help applying for public benefits, assistance to achieve wellness by coordinating timely and appropriate healthcare appointments, providing transportation to healthcare appointments, and working collaboratively with patients, physicians, family, and other providers to implement a plan of care that meets the patient’s needs for quality, safe, and cost effective care.

How does the innovative program work to improve behavioral health access?: 

According to Healthy Montgomery, behavioral health disorders are a very real problem in Montgomery County: 1) One in ten Montgomery County respondents to the 2009 Behavioral Risk Factor Surveillance System (BRFSS) reported being diagnosed with an anxiety disorder, 2) 16.8% of Montgomery County respondents to the 2009 BRFSS reported being diagnosed with a depressive disorder, and 3) In 2010, there were 741.2 visits per 100,000 Montgomery County residents to the emergency room for a behavioral health condition.

Use of the emergency room by behavioral health patients implies a great lack of access to community resources for this population. CareLink improves access to healthcare by connecting behavioral patients with the appropriate community resources.  CareLink schedules healthcare appointments in the community, provides transportation, and provides intensive case management services for patients, thereby forging new healthcare relationships for patients and increasing access to care.

How does the innovative program work to improve behavioral health quality? : 

Lawmakers and healthcare leaders are attempting to address the health disparity among those with behavioral health disorders. The problem encountered by the target population is that these patients often have limited knowledge of and/or access to medical and mental health services that may be available to them and therefore utilize the Emergency Department since they know hospitals are required to see them there. However, the Emergency Department is generally only able to address a patient’s immediate needs and does not provide any follow-up care.  Frequently, those with behavioral health disorders need a helping hand after they leave the emergency room in order to obtain medications, secure transportation to follow-up appointments and follow through with referrals to a primary care medical home, specialty care, or outpatient mental health treatment.  CareLink provides these case management services for patients so they get the right care at the right time.

How does the innovative program work to address behavioral health costs? : 

In the first two years of the program (2012-2014), CareLink saved participating hospitals $3.6 million dollars.  Hospitals have incentives to purchase or provide care outside their primary buildings, as each hospital re-admission costs them between $13,000 and $15,000.  Comparatively, hospitals pay CareLink approximately $750 for most patients.  As more people become insured, patients have options to use community based services.  CareLink emphasizes the use of these services and provides extensive patient education on access to community care and benefits.  In turn, this reduces the burden on hospitals and allows the focus to fall on patients who do need an acute care facility.  The community at large also benefits from the program so that the Emergency Department is reserved for those patients experiencing a true emergency.

Creativity and Innovation: 

CareLink has been recognized as a unique program of promise to help hospitals work with clients who frequently re-admit to the hospital for reasons that could be prevented.  Our model utilizes Community Health Workers - staff who frequently meet with clients at local libraries, gas stations and fast food restaurants to assist in the transition from hospital to community.  We have also worked a great deal with the homeless population in our area which has historically been quite difficult to engage.  One very practical area that we have shown our creativity has been in communicating with our clients while they are in the community.  Our relationships with local hospitals allow us to provide  them with cell phones to give to our clients when a referral is warranted after hours or on weekends and the social worker then provides us with the phone number so we may contact patients.


Family Services’ role with the Maryland Behavioral Health Network (MBHN) has allowed us to discuss this venture with other behavioral health leaders. The Director of CareLink presented the program to a broad audience over the last 2 years at the National Council on Behavioral Health Annual Conference and has led discussions with numerous key stake holders throughout the country about this program. Further, the Program Director participated as a co-facilitator of a webinar sponsored by SAMHSA-HRSA regarding hospital readmissions and care coordination after discharge.  This webinar was attended by more than 1,000 people and has been viewed numerous times on the HRSA website.  This webinar also led to more than 10 conversations with hospitals throughout the United States about how the program works and how it may be implemented in their communities.  Recently, the program director worked hand in hand with Gracepoint Wellness in Tampa, FL to implement there.


CareLink is greatly needed at this time, as Maryland's CMS waiver from 2014 focuses on reducing 30 day hospital readmissions.  In 2011, 30 day hospital readmissions cost $657 million in Maryland with the average cost of one being $13,000.  It is estimated that 18% of all Medicare patients discharged from the hospital readmit within 30 days, costing our nation $15 billion.  Instead of this costly, unexpected expense for the hospitals, each hospital pays CareLink a modest fee to implement the program - saving them millions over the years.  In the last four years since CareLink launched, we have served 800 patients and reduced 30 day hospital readmissions by over 84%.  In March 2015, Family Services was selected to receive a $250,000 two year grant from the MD Community Health Resources Commission to expand CareLink to a third and fourth hospital.  Family Services will continue to seek supplemental grant funding.


CareLink Transitions has been shown to be replicated both locally and in other areas of the state.  Within the last year, we expanded services to include Holy Cross Health, including two local hospitals.  This replication occurred without major difficulty and only needed slight modification to fit into the Holy Cross system of care.  Another example of our history of replication occurred recently when Go-Getters, an outpatient mental health provider on the Eastern Shore of Maryland, received a grant from the Maryland Community Health Resources Commission (MCHRC) to start a program replicated off the CareLink model in their community.  Interest in this replication started after hearing of the success we have had in Montgomery County and discussions at the Maryland Behavioral Health Network (MBHN).


The overall project goal is to reduce hospital readmissions within 30 days for the patients referred to CareLink Transitions.  The data around hospital re-admissions currently is obtained through client self-report and manually looking up each client referred in CRISP.  This data is then imported manually into Care Coordination System software for reporting and analysis.  CCS also allows us to track other key performance measures such as: 

  • Nurse care managers identify barriers to outpatient treatment at first visit, within 24 hours of referral, and develop care plan to keep patient from returning to the hospital or the emergency department.
  • Benefits coordinator meets with patient and community health worker to assist in application of public benefits, housing referrals and other needs within the first 5 days of referral. 
  • Community health worker assists in completion of needs assessment (Initial Adult Profile) to identify needs within 24 hours of referral to program.