Our Need for 'General Contractors': The Foundation of Proper Behavioral Healthcare Depends on Care Continuity

Article excerpt

Consider the following: You have just completed work with an architect to design a wonderful new house for your family. After you purchase the site, one team comes to dig and pour the foundation, and another comes to construct the walls. However, the team needed to install the roof never arrives. The walls and foundation are ruined by ice and snow. Unlikely? Not if you neglect to engage a general contractor to organize and mobilize the construction teams in an appropriate sequence. You say, "I would never let this happen to my new house." Why, then, do we allow it to happen to behavioral healthcare services?

Continuity of care has emerged as the crux of a major problem because it has great potential to fail. Many consumers either do not successfully span the chasm between inpatient and community behavioral healthcare services or do not become engaged in community care once they arrive there. (Similarly, many consumers do not successfully negotiate the chasm between behavioral and primary care services.) The negative consequences of such failures can be devastating. They may include becoming homeless, running out of needed meds, not receiving needed peer support, reentering the hospital after just a short period, or even death. Consumers and family members do have a very strong vested interest in successful care continuity.

Recently, two key meetings on care continuity were held in Washington, D.C. One focused on implementation of a study on how behavioral healthcare continuity currently operates; the other, on major steps that need to be taken to improve continuity. Here, I would like to discuss some of the factors that cause continuity to fail and some of the actions we can take to rectify this situation.

Continuity fails frequently because there is no "general contractor." The inpatient provider may attempt only a perfunctory effort at coordination, i.e., simply fax the care record to a community provider; the community organization may not engage in outreach to facilitate continuity; system managers may not permit resources to be expended on this function; accreditation standards may not address the topic; and no integrated care record (either electronic or paper) may be available. The net effect is that the consumer leaves inpatient care with a less than evenhanded chance of receiving community care in a reasonable period.

What is needed to improve behavioral healthcare continuity? The following strategies should be considered as we begin to address this important problem:

Revising policies and procedures. At the most fundamental level, we need policies and procedures that encourage both the sending and receiving programs to coordinate care transfer effectively. Accrediting entities should examine current practices and insist through appropriate standards that effective continuity actually becomes part of the treatment regimen, and that periodic reviews be conducted for potential improvements. …