Mental Health Participant Handoff: The community feedback period for this idea began on 7/2/2019 and ended on 8/31/2019

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).

Additional Information:

June 19, 2019


Innovations Team

Thank you for your submission. The innovation team needs additional information to explore this proposed idea. Please elaborate on your responses as best as possible so that we may work through our review process.

•Within Orange County Mental Health, coordination of care handoffs from the transferring provider to the new provider are already being conducted. As long as releases of information are in place, ongoing coordination of care efforts also occur between the provider and any other agencies providing services to the patient. It is unclear what the innovative component is for this idea. Is it that a more formal handoff process be developed?

This submission was one of a few to break out specific not-so-obvious components of a Patient Centered Medical Home. This submission was provider/referral network agnostic. Within a referral network I expect hand-offs to occur. When a person crosses between two or more referral networks there is less incentive for hand-offs. A person that is not well oriented may also not be able to share what referral networks are applicable – a case where the hand-off depends upon the patient to be successful.

This submission was intended to address a possible need of people on a private payer (non-Medicaid, non-Medicare, non-Medi-Medi) and thus not eligible for Orange County Behavioral Health services. This submission could also address a possible need of people that find it necessary to utilize numerous referral networks.

This submitter does not fit either of these two categories anymore and thus isn’t able to advocate well for this idea. This idea could possibly be seen as a subsidy for wealthy, disorganized payers. Reguardless, others who fit into these categories can advocate for themselves by submitting comments below.

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