How It Works
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Admission & Assessment – Participants admitted to the RCH Behavioral Health Unit are assessed by our team. Based on their needs, they are connected with a provider, taking into account existing relationships, specialties (such as substance abuse or LGBTQIA+ care), and personal preferences.
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Case Management Support – Our Case Managers and Community Health Workers assess Social Determinants of Health (SDOH), connect participants with resources, and ensure a primary care provider (PCP) is in place before discharge.
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Daily Counseling – Participants receive counseling through the Mental and Emotional Health Series, providing tools to initiate the healing process.
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Collaborative Care Transition – Partner agencies meet with participants during admission to ensure a smooth transition of care, with follow-up visits scheduled within 7 days of discharge.
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Medication Support – Before leaving the hospital, participants are given prescribed medications with clear dosage instructions to improve adherence and recovery.
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Ongoing Follow-Up – For six months post-discharge, Case Managers coordinate monthly follow-ups with partner agencies to reassess needs and ensure continuity of care.
Primary Care Visits
At least 75% of participants will have a primary care appointment within one month of enrollment.
Behavioral Health Visits
At least 75% of participants will see their behavioral health provider within 7 days of discharge.
Readmission Reduction
Hospital readmission rates will be reduced to below 20% within 30 days of discharge.
Medication Adherence
Participants’ medication adherence will at least double in the 6 months following enrollment.
Sustained
Care
65% of participants will continue monthly behavioral health visits in the 6 months following discharge.