New Behavioral Health Discharge Follow-Up Assessment

Date: December 20, 2024

Attention: Behavioral Health Providers

Call to action: We are excited to announce the implementation of a new Behavioral Health Discharge Follow-Up Assessment, designed to improve care coordination and support for our members at a vulnerable time in their health care journey. 

The assessment, performed by our dedicated and highly-skilled staff of service coordinators, is used to assess members:

• After discharge home from an inpatient behavioral health admission.
• After discharge home from an emergency department visit for mental illness.

How this impacts providers: Key Features of the Follow-Up Assessment:

• Discharge Plan Review: Evaluates the legally authorized representative (LAR) or adult member’s understanding of discharge instructions, that they are comfortable with the plan of care, and know who to contact if they need support. 
• Care Management: Assesses comprehension of medication changes and whether the member was able to access prescribed medications.
• Timely Follow-Up: Ensures the member has an appointment scheduled with a behavioral health provider within 7 days of discharge.
• Barrier Identification: Identifies potential barriers to follow-up care, such as transportation issues, and provides assistance to overcome them.
• Risk Level Assessment: Provides the service coordinator an opportunity to evaluates the member's risk level to ensure they are appropriate and stable for outpatient care.
• Resource Provision: Offers care coordination services, including scheduling follow-ups and connecting members with community resources.

If this assessment is completed for one of your patients, you will receive the results by one of the following means: 

• secure email
• Fax
• Telephonically
• Epic In-Basket Message

We recommend reviewing the information and adding it to the patient’s medical record for future clinical decision-making.

This process ensures you are informed about the patient’s post-discharge status and any additional support provided by our team. By working together, we can enhance follow-up care and improve outcomes for your patients, our members.

Next step for Providers: It is highly recommended that providers utilize the information from the follow-up assessment when creating future care plans for their patients. Providers should share this communication with their staff. 

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org. 

For access to all provider alerts:https://www.texaschildrenshealthplan.org/providers/provider-news/provider-alerts.