Yes, We Can! Build Bridges Back to the HCH Medical Home after Mental Health Hospitalization

Ensuring access to care from inpatient setting to outpatient medical home is challenging.   Fragmented hospital discharge processes often result in preventable re-hospitalizations and overuse of resources, with additional stress and re-traumatization for homeless consumers -- a ‘high need, high cost” population.  A “Bridge” project uses Critical Time Intervention to increase access, patient-provider stability and positive peer support.  Other features include interdisciplinary teamwork, increased hospital collaboration, and a mental health in-reach team that promotes the medical home with patients before discharge.   Post-discharge continuity includes ‘fast-tracking’ patients using an outpatient ‘Bridge to Care’ group, treatment readiness preparation, and medication evaluation.