The Mental Health Center of Greater Manchester (MHCGM) has launched a new Behavioral Health Intensive Transition Team (ITT), which will support the needs of high-risk children and adults discharged from Emergency Departments of Catholic Medical Center or Elliot Health System. The new team will support individuals as they progress through a continuum of acute care services. Following the completion of a Shared Care Plan, a multi-disciplinary core team comprised of PCPs, health care and behavioral health providers, peer support specialists and case managers will be assembled around the patient to ensure critical needs are met and connections to appropriate services are secure. MHCGM has partnered with the Elliot Hospital, Catholic Medical Center, Dartmouth-Hitchcock, Manchester Community Health Center and a number of community support service organizations to better align our network of partner service providers and to insure all individuals have access to care.
The warm hand-off within the network of providers will help the individuals (and/or family members of children) to create a care plan, make lifestyle changes and develop crisis management strategies. Patients will be followed and supported for approximately 30-45 days post hospitalization discharge to help prevent re-hospitalization. Particular focus will be placed upon connections to and from primary care for those receiving services.
Reasons for focusing on Transitions of Care include; Inpatient to outpatient transitions are particularly problematic from an individual, health system, and societal perspective and significant risks include care disengagement, symptom exacerbation, and hospital readmissions. The specialized Intensive Transition Team will act as a “safety net” for the target population and will serve to Improve transitions of care from acute services to primary care and outpatient behavioral health settings, while enhancing patient outcomes.
The Intensive Transition Team (ITT) will complement other existing programs of The Mental Health Center such as our Mobile Crisis Response Team (which aims to divert hospitalization) and the Network4Health Care Transitions Team, whose network of services for re-integrating back into the community post-release from the criminal justice system, inpatient hospitalization, and youth to adult services; offers a support system for high-risk individuals to manage their ongoing recovery. Within our continuum of care, The Mental Health Center of Greater Manchester also operates the Cypress Center, a 16-bed acute psychiatric residential treatment program that serves as one of the three remaining Designated Receiving Facilities for adults in New Hampshire. Through a Shared Emergency Services Response System with Catholic Medical Center and Elliot Health System, our Emergency Services & Interim Care division operates 24 hours per day, 7 days a week and offers a daytime walk-in center along with follow-up crisis stabilization services and interim outpatient care.
The new Intensive Transition Team will be fully operational by mid-August 2018.