What is the problem that needs to be addressed? Please describe how it is related to mental health.
Hand-offs between mental illness/homeless service providers do not occur in Orange County, CA. Because we don’t have a Patient-Centered Medical Home in Orange County, CA for homeless/mentally ill individuals, it is dependent upon the homeless/mentally ill individual to conduct their own patient handoff to the next service provider. Based upon delirium, mental illness, lack of orientation, etc it is unlikely that the self-referral handoff is very successful.
Why is this a concern for Orange County? What can Orange County and other counties learn from this project?
Orange County, Cal-Optima and other payers spend lots of money on homeless/mentally ill individuals. Having adequate handoff communication is important. People who have significant morbidity and deemed that treatment is worse than non-treatment need to have this communicated with other service providers within Orange County for informed decision making. It is unfair to drop off a person with an untreated hip-fracture to a day program and expect the day program to work with that person during significant pain, gait disturbance, etc. Occupational Therapy plans are also not shared between service providers (assuming that such plans even exist). OT plans are important, especially when behavior issues arise and a person may be exited from a service provider for significant periods of time.
What is currently being done to resolve this problem in our county and throughout the United States? If applicable: Is it working; why or why not?
Currently, 13+ Psychiatric wards operate in Orange County – most within their own referral network. Numerous day programs, County contractors and other entities work as their own, independent and isolated service. There is no known handoff between these providers, except for what the mentally ill/homeless person is able to share. There is no known research that measures the outcomes of depending upon a mentally ill/homeless person to do their own handoff to the next service provider.
What is new or different about this project idea? Please describe how this differs from what is already being done (Question 6). Please list any research that was done on this topic.
This is a platform project – meaning the platform isn’t novel, but having the platform provides significant data sharing, learning and efficiency opportunities.
What is the project idea? Please describe how this project will operate.
Have case handoff between all the entities that serve homeless/mentally ill persons in Orange County. The handoffs don’t need to cover extensive medical data, but just the important things (i.e. a person has an untreated joint fracture, a person has Occupational Therapy plan meaningful to a day program, a person has coronary artery blockage that impairs cardiovascular activity so don’t encourage them to exercise, a person has end-stage organ failure so don’t expect them to do much/expect them to be in pain, etc).