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.