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Care Transitions Support Services

A primary goal of the Care Transitions Network is to reduce all-cause re-hospitalization rates for people with serious mental illness. To support progress in this area, the Care Transitions Network offers short-term care transitions support services between inpatient and outpatient settings enrolled in the network through our partners at Montefiore’s University Behavioral Associates (UBA).

A primary aim of this intervention is to improve connection to outpatient care for patients after discharge from psychiatric hospitalizations. With that goal in mind, we offer support for your discharged patients in the following areas:

  1. Increasing connections to Health Homes by (a) notifying care managers of enrolled members’ hospitalizations or (b) making bottom up referrals to a local Health Home for members who are eligible but not yet enrolled
  2. Engaging with patients telephonically for the 30 days following discharge to facilitate their attendance at outpatient appointments (both behavioral and medical), and rescheduling their appointments if there is a barrier to attending appointments as scheduled
  3. Confirming outpatient appointment attendance with providers (both behavioral and medical) in order to track 7- and 30-day follow-up outcomes and re-engage patients as necessary to help them better connect with outpatient care

If you are interested in receiving these services, please contact Sarah Overholt at or 718-920-7971.

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.