Onsite Care Support in Behavioral Health

Embedding Care Managers in Alcohol and Drug Addiction Treatment Facilities to Deepen Support

The following Healthfirst, Behavioral Health, Care Managers contributed to this article: Andrea Pressman, Kelly Rumm, Kelly Malloch, Stefanie Matthews,

Nearly 3 million New Yorkers over the age of 12 had a substance use disorder (SUD) in 2022, meaning a recurrent use of alcohol and/or drugs impairs their ability to fulfill major obligations at work, school or home.

When a SUD develops some people receive treatment at an inpatient rehabilitation center. Unfortunately, it is common for patients with SUDs to be readmitted after receiving treatment — one study found 42% of patients were readmitted at least once within a year after discharge. This may be because of disjointed, unrealistic discharge planning and lack of connection to community support.

Many members with SUDs also have health-related social needs that impact their overall well-being, such as housing or food insecurity. This impacts their ability to continue on their recovery journey after leaving the inpatient facility.

Because of a recent program we implemented at Healthfirst, members who are admitted to inpatient centers for detoxification and/or rehabilitation now receive extra support both during their stay and after they return to their community.

The importance of discharge planning

Proper discharge planning for any inpatient stay, be it from an acute care hospital or a rehabilitation facility, is of utmost importance. Just like having a plan in place for discharge after an acute hospital stay can prevent a readmission, having a personalized discharge plan set up while still in a rehab facility — one that includes follow-up appointments and connections to community support — may reduce the likelihood of readmission and extend a member’s tenure in the community.

Health plans are even measured on their ability to connect with members after an inpatient rehabilitation stay — a HEDIS measure tracking the percentage of inpatient hospitalizations, residential treatment discharges for SUD resulted in follow-up care within 7 and 30 days.

But connecting with members after they leave an inpatient facility can be difficult. Traditional telephonic outreach is only so successful when it comes to completing transitions of care and linking them to appropriate follow-up treatment.

A face-to-face connection

That’s why a program at Healthfirst embeds Healthfirst care managers in the inpatient facility and integrates them into the staff. These onsite care managers make face-to-face connections and build trust with members during their stay, and work with existing staff to develop personalized discharge plans for each member. The care managers also continue to follow up with members post-discharge to ensure they keep appointments and are connected to the community resources they need.

Beyond being licensed social workers or mental health counselors, the care managers bring a level of familiarity to members because they live in the communities they serve and understand what is happening in the neighborhood.

So far, seven Healthfirst care managers are stationed in four SUD facilities in Queens, Harlem and Brooklyn. Our goal is to have care managers in 10 to 15 facilities by the end of the year.

While it’s still too early to report data on the success of this program, participating facilities have provided positive feedback about the embedded care managers. When all systems work collaboratively, we can achieve so much more for our members.