Eliot’s Behavioral Health Community Partner Program utilizes a team approach designed to enhance care coordination and integration of behavioral and physical health services for individuals with complex behavioral health, medical and/or substance use disorders to improve outcomes.
- Outreach and active engagement of assigned members;
- Identify, engage, and facilitate member’s care team, including primary care physicians, behavioral health providers, and other providers and individuals identified by the member, on an ongoing basis;
- Conduct comprehensive assessment and person-centered treatment planning across behavioral health, long term service supports, physical health, and social factors that leverages existing member relationships and community behavioral health expertise;
- Coordinate services across continuum of care to ensure that the member in in the right place for the right service at the right time;
- Support transitions of care between settings;
- Provide health and wellness coaching; and
- Facilitate access and referrals to social services, including identifying social service needs, providing navigation assistance, and follow-up on social service referrals, including flexible services where applicable.
One in five adults experience mental illness each year and one in twenty experience serious mental illness. Eliot’s Behavioral Health Community Partner (BHCP) Program highlights that targeting resources, fully integrating teams, developing care plans that encourage patient buy-in, and attending to outcomes are the building blocks of improved health and overall wellness for individuals experiencing challenges related to mental health, substance use, and complex physical health issues. Specifically, a recent analysis found that individuals engaged in Eliot’s BHCP had:
- Improved access to Outpatient Behavioral Health Care;
- Improved medication adherence;
- Improved behavioral health follow care after a psychiatric hospital discharge;
- Improved access to preventive physical health care; and
- Reduced psychiatric admissions and readmissions.