The current healthcare system in our service area does not inherently support continuity of care and transitions among systems resulting in a higher rate of preventable emergency room visits, hospitalizations and jail bookings for those with behavioral health and co-occurring substance use needs. Recent briefs issued by the Agency for Healthcare Research and Quality suggests that care coordination models “assist patients and their support systems in managing medical conditions more effectively.” Further, the brief indicates that care coordination and management is key to managing population health outcomes.
Through this grant application, Bluebonnet Trails Community Services intends to bridge the gaps supporting effective continuity of care resulting in higher rates of preventable emergency room visits, hospitalizations and jail bookings. By increasing care coordination to all individuals in our services regardless of indigent status or the program in which the individual is participating, individuals will receive timely, meaningful assistance in navigating multifaceted healthcare systems in their home communities, ensuring the individual receives needed primary and specialty care. In addition, the care coordinators foster clear communication between the individual and all providers of care improving the experience and healthcare outcomes for the individual.