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The Care Transitions Network for People with Serious Mental Illness helps organizations in New York State move into value-based payments and reduce all-cause re-hospitalization rates for people with serious mental illness, through:

  • Expert faculty who provide targeted coaching, best clinical support services and organizational trainings and resources to help implement evidence-based practices and transition to value-based payments
  • A web-based platform with clinical, financial, and utilization data that enable practices to establish benchmarks, track progress, and make informed business decisions
  • Short-term care transitions support that ensures patient engagement with outpatient practices and health homes after discharge from psychiatric hospitalization

About the Network

The Care Transitions Network consists of providers across the continuum of care in New York State: inpatient, outpatient, rural, urban, small, large, behavioral health and primary care practices.

The Care Transitions Network provides supports and resources to clinical and administrative staff alike. Each organization has at least one “eligible professional,” defined by CMS as Physicians, Nurse Practitioners, Physician Assistants, Clinical Psychologists and Licensed Clinical Social Workers. (See the list for a full list of eligible clinicians).

Benefits of the Network

Providers within the Care Transitions Network gain insight into evolving state and managed care-level policy related to value-based payments, receive Medicaid spending data about their behavioral health population, and access on-demand coaching from recognized experts in practice improvement, health care administration and managing the clinical care of people with serious mental illness.

The Care Transitions Network is made possible by a grant made to the National Council for Behavioral Health by the Centers for Medicare and Medicaid Services, in a partnership between the National Council, Montefiore Medical Center, Northwell Health (formerly North Shore-LIJ Health System), the New York State Office of Mental Health and Netsmart Technologies. Contact us by emailing or calling 202-849-4920. The project described was supported by Funding Opportunity Number CMS-1L1-15-003 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. Disclaimer: The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.