Research
Continuity of Care Agreement

Investigator: Kathleen Kim, M.D., Ph.D.

The office of Mental Health of the Department of Human Services had based the design and implementation of a unified, integrated and coordinated public mental health system on the values and principles of comprehensive community based systems of care as established in the community support program (CSP) and Child and Adolescent Support Services Program (CASSP) models of the federal Center for Mental Health Services (CMHS). These models represent more than a series of service components. Rather, they represent a philosophy about the way in which services should be delivered to adults with serious mental illness and children and adolescents with serious emotional disturbances.

This agreement defines a systematic approach and operating criteria for the provision of care in conformity with the therapeutic needs of the client and based on the belief that individuals with mental illness are best served when they have access to basic community supports as well as specialized mental health services. State hospitals serve as an underlying support of the mental health service system, providing tertiary, intensive inpatient services for those individuals with needs which cannot be addressed by other components of the service system. While state hopitalization is a part of the continuum of services, the community is usually the best place for providing the majority of mental health services an care and based on this principle, the clinet's care is viewed primarily as the responsibilty of the provider agency, reagardless of the location of service. Thus, continuity of care requires involvement of the provider agency in the provision of services in the community, in screening for inpatient admission, in the planning and provision of inpatient treatment, in planning for discharge, and in providing post-hospital care.

The agreement sets forth the constractual roles, responsibilities and re;lationship of the provider agency and the Office of Mental health's state hsopitals in prociding coordinated care in individuals who are triaged (assessed for psychiatric hosptialization but found not to meet the criteria for admission to inpatient care with disposition to an appropriate altenative level of care), admitted or discharged from state hosptials. For forensic slients admitted to state hosptials it is recognized that Sections IV and V of this Agreement are not applicable; however, all other Sections of this Agreement apply to forensic as well as non-forensic clinents admitted to state hosptials.