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The National Council for Behavioral Health, in partnership with Montefiore Medical Center, Northwell Health (formerly North Shore-LIJ Health System), the New York State Office of Mental Health and Netsmart Technologies, has launched the Care Transitions Network for People with Serious Mental Illness (SMI). This four-year initiative in New York State was made possible by a $29.4 million Transforming Clinical Practice Initiative grant awarded by the Centers for Medicare and Medicaid Services. The Care Transitions Network joins 28 other Practice Transformation Networks around the country working to create new and replicable models of care for vulnerable populations and helping provider practices move into the world of value based payments.

The Vision

The Care Transitions Network, in partnership with behavioral health providers and primary care providers across New York State, will reduce all cause re-hospitalization rates by 50 percent for people with SMI, while simultaneously helping organizations move forward with value-based payment arrangements.

The Problem

According to the New York State Office of Mental Health, 82 percent of patients with hospital readmissions have mental health or substance use disorders. While these patients have psychiatric diagnoses, the majority (59 percent) of the readmissions are for medical disorders.

Patients with SMI have shorter lifespans because of co-morbidities, including higher than average rates of obesity, hypertension and smoking addiction. As a result, they have greater incidences of cardiovascular, cerebrovascular and other tobacco-related illnesses.

Adding to this problem, historically siloed systems of care have resulted in disjointed and incomplete care transitions between hospitals and outpatient primary care, mental health and addiction treatment services.

In addition, to public health concerns regarding SMI, the shift toward value-based payment structures means that providers face significant financial risks when treating this high risk population.

These problems are not unique to New York State. In fact, New York has led the of promotion of evidence-based practices and creation of infrastructures to support practice transformation. The Care Transitions Network will use the groundwork already laid to accelerate adoption by the field.

Practice Transformation

The Care Transitions Network will support more than 4,000 clinicians across New York State to implement evidence-based treatments for people with SMI, including individuals with schizophrenia, bipolar disorder and chronic depression. It will enable primary and behavioral health care integration, ensuring that inpatient and outpatient providers bridge the gap at discharge and payer and provider priorities are better in sync.

Working with practice coaches, enrolled organizations will move through five phases of transformation, from setting aims around the use of data to thriving as a business through pay-for-value approaches.


Over the four-year life of the project, the Care Transitions Network anticipates avoiding 16,000 hospitalizations and generating $186 million in savings.

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.