Liaisons Ensure Continuity Of Care In Crisis

Many people in a mental health or substance use crisis seek help in a hospital emergency department (ED), where that crisis may be seen as a distinct episode with little continuity or communication about the person’s past or what happens after they leave. Because of this, Alliance Health’s care management team has a robust ED liaison system designed to ensure continuity of care, improve outcomes and possibly reduce repeat ED visits for the people we serve.

Six Alliance care coordinators currently serve as ED liaisons, coordinating and communicating between the EDs and other care coordinators and community-based services, including two Wake County school-based care coordinators who offer assistance to Wake County Public School system (WCPSS) students and their families.

Whether the member is discharged and connected to community supports or referred to an inpatient program, the goal is to establish continuity of care. “Our job is really a lot of communication, collaboration and brainstorming.” Said Adam Shields who serves as the ED liaison at Wake Med’s main ED in Raleigh, and backup for Ashley Marrow, who works with Rex and Duke Raleigh as well as the five other Wake Med EDs. Marrow also serves as backup for Shields.

Senitra Pryor works in Durham with Duke University and Duke Regional hospitals, including the inpatient psychiatry wards at each, and Melinda Short covers Cape Fear Valley Medical Center and its behavioral health center.

As part of Alliance’s School Based Team (SBT) partnership with WCPSS, school-based care coordinators Catherine Lilly and Christopher Toller monitor ED and crisis facility admissions to identify WCPSS students and link them to appropriate behavioral health and community resources to support them in their transition back to school after a crisis episode.

The ED liaisons have an app that allows them to see the facilities’ daily admissions and review the behavioral health cases. Then they partner and collaborate with the hospital social workers, providers and other community resources to get people diverted out of the ED if appropriate, or work on a discharge and continuity plan if someone has been admitted for observation. If the member has a care coordinator they are alerted, if not a care coordinator is assigned to ensure the member maintains connection to care after the crisis.

“We are making sure no one falls through the cracks and that care coordinators know when their members are there.” Short said. “A lot of times people in crisis don’t know their provider’s information or when their last date of service was, so we can make sure the social worker has the information they need at the time.”

For WCPSS students, the liaisons reach out to a child’s parent to see if they are interested in having additional support. If so, they get a signed consent and assign a school-based liaison who coordinates with the school, notifying them that a student is in the hospital. “The main goal is to support the student as they transition back to school after the hospitalization,” Lilly said. “This involves tailoring the child’s support to their specific circumstances,” she said.

The support goes beyond healthcare to addressing what are commonly called the social determinants of health, so the liaisons have a conversation with members about their needs. “Many people have a lack of resources including food insecurities or lack of transportation, so we try to ensure that they have that before they leave,” Pryor said.

The COVID-19 pandemic has multiplied some of the stressors that may push people into crisis, adding new pressures to school students. “There’s already the pressure and anxieties that come with that age and then on top of that you have virtual learning and feeling disconnected from peers,” Toller said. “The routine has changed so drastically, plus you have the pressures of parents and children all trying to work at home.”

Economic pressures may also increase the amount of stress in the household, multiplied for families who are facing homelessness. The liaisons can connect members and families with housing resources, which for Wake students includes the McKinney-Vento program, which addresses the needs of children and youth experiencing homelessness. Last summer the SBT liaisons were able to get Independent Living Initiative (ILI) funding for the family of a child with medical issues, which allowed them to move into a home. Another family of several Wake children were staying in a motel, but internet access issues made it difficult to register the kids for schools so Toller coordinated with a social worker to get the kids registered.

“I think of how hard it is for so many adults to adjust, and it’s something that no one could have prepared any young person for,” Toller said.

To learn more about crisis alternatives to the ED, visit the Alliance website.

Learn more about the Alliance School Based Team in its 2019-2020 annual report.