The most problematic area for individuals who suffer from mental illness is the successful transition from inpatient hospital to outpatient care. Given the cognitive and motivational deficits that are part of mental illness, the ability of these individuals to navigate the complex and often frustrating community-based services leads many to drop out of treatment before even becoming successfully engaged. Often these individuals find themselves readmitted to the hospital and suffer worsening effects of chronic institutionalization. Families are often left with the burden of caring for their chronically ill relatives with little education concerning the disease process or the potential treatment available.
The Behavior Health Home Care Program will act as a tool for both families and patients. The goals of this program will be:
- Assessment and supportive treatment of individuals within the community.
- Education of family members and patients concerning the nature of their illness and the available treatments.
- Provision of “bridge” services to individuals and follow up for patients in the community until they successfully connect with community-based outpatient programming.
- Facilitation of interdisciplinary collaboration across the continuum of care.
- Patients will be initially identified within the inpatient facilities of Catholic Health Services of Long Island, as well as screened from within the Home Care Agency.
- Patients will be screened by the Behavioral Health Team Manager or designee prior to admission.
- Those who are inpatients on a psychiatric unit may have a Behavioral Health Nurse meet with them prior to discharge.
First Visit in the Community
- For those coming to the home care program following admission to an inpatient psychiatric unit, a Start of Care Assessment will be made within 48 hours of discharge from the facility.
- Goals and interventions will be identified and an individual plan of care developed.
- Assessment of educational needs and provisions of such education will follow.
- Follow up appointments will be made based on need.
Follow Up Visits in the Community
- Ongoing assessment of patient’s mental state.
- Ongoing assessment of compliance with medication.
- Ongoing assessment of psycho-educational needs.
- Supportive therapeutic interventions primarily based on behavioral interventions.
The patient will be discharged when established goals have been met:
- Patient has successfully followed up in outpatient care and/or community-based services.
- Patient refuses ongoing care in the community.
- Patient requires re-admission to an inpatient facility.
- Patients with Axis I or Axis II Disorder.
- Any patient who when screened upon admission to home care services, that may require/demonstrate the need for behavioral health intervention in accordance with the Primary Care Physician orders.
- Primary substance abuse disorder
- History of violence
- AOT or ACT involvement
- Lack of housing