Community-based care

 

The program being discussed is a follow team. After meeting with one of our responders (clinician, peer support, police officer, firefighter or EMT) during a crisis, a resident may need additional support connecting to community-based care. CN provides dedicated follow-up, either in person or over the phone, from a clinician and peer support after the initial 9-1-1 crisis interaction.

The Goal: Increase the likelihood that people connect with community-based care, reduce unnecessary use of the emergency room, and decrease the number of people who experience multiple crises.

Questions:

1.) the follow up team will go from working 8 hrs to a 12 hr rotation. What will they do during the evening hours when referral agencies are closed?

2.)what does a warm handoff look like when this is appropriate?
3.)How do you ensure continuity of care when staff are working a rotating schedule?
4.) How to ensure an equal distribution of work amongst staff?
5.) What does quality assurance look like for this follow up program?

Sample Solution

1. What will the follow-up team do during the evening hours when referral agencies are closed?

During the evening hours when referral agencies are closed, the follow-up team will focus on providing support to individuals who have recently experienced a crisis. This support may include providing emotional support, helping individuals to develop coping skills, and connecting individuals with resources that are available 24/7. The follow-up team may also use this time to conduct outreach to individuals who have not yet connected with community-based care.

2. What does a warm handoff look like when this is appropriate?

A warm handoff is a process of transferring care from one provider to another in a way that ensures continuity of care. This can be done in person, over the phone, or through electronic means. When a warm handoff is appropriate, it is important to provide the following information to the new provider:

  • The individual’s name, contact information, and insurance information
  • The individual’s history of mental health and substance abuse treatment
  • The individual’s current mental health status
  • The individual’s goals for treatment
  • The individual’s treatment plan

3. How do you ensure continuity of care when staff are working a rotating schedule?

Continuity of care can be ensured when staff are working a rotating schedule by using a variety of strategies, such as:

  • Developing a clear and concise communication plan
  • Using electronic medical records that are accessible to all staff
  • Holding regular team meetings to discuss individual cases
  • Providing training on how to provide warm handoffs

4. How to ensure an equal distribution of work amongst staff?

An equal distribution of work amongst staff can be ensured by using a variety of strategies, such as:

  • Developing a workload allocation plan
  • Using a time tracking system
  • Holding regular team meetings to discuss workload
  • Providing feedback to staff on their workload

5. What does quality assurance look like for this follow-up program?

Quality assurance for the follow-up program can be achieved by using a variety of strategies, such as:

  • Developing clear and measurable goals
  • Collecting data on the program’s outcomes
  • Monitoring the program’s progress
  • Making changes to the program as needed

By using these strategies, the follow-up team can ensure that the program is providing high-quality care to individuals who have recently experienced a crisis.

In addition to the above, here are some other considerations for the follow-up team:

  • The importance of training: The follow-up team should receive comprehensive training on crisis intervention, mental health, and substance abuse treatment. This training will help the team to provide effective support to individuals who have recently experienced a crisis.
  • The importance of collaboration: The follow-up team should collaborate with other agencies and organizations that provide services to individuals with mental health and substance abuse challenges. This collaboration will help to ensure that individuals receive the most comprehensive and coordinated care possible.
  • The importance of evaluation: The follow-up team should regularly evaluate its effectiveness. This evaluation will help the team to identify areas where it can improve and ensure that the program is meeting the needs of the individuals it serves.

By considering these factors, the follow-up team can ensure that it is providing high-quality care to individuals who have recently experienced a crisis.

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