This resource is a part of our “snapshot” series. A snapshot is a point-in-time window into our process for developing, testing, and implementing programs and partnerships. Snapshots let us share our hypotheses, workflows, and early observations and findings quickly with other innovators who are interested in what’s happening on the ground right now.

For more up-to-date and comprehensive information about the Pledge to Connect program, please visit the program page.

Issue

Individuals with behavioral health (BH) needs often seek care from multiple emergency departments (EDs) across health systems in their region, resulting in inefficient care delivery, poor continuity of care, and lack of engagement in appropriate outpatient care. Existing communication practices and IT systems are not set up to support multi-provider clients nor to integrate data between traditional health systems and community-based behavioral health providers.

Project goals

Pilot a regional triage model across four health systems in five South Jersey counties that leverages a data-driven approach to:

1. Identify patients using multiple emergency departments across the region for behavioral health-related needs,
2. Bring providers across systems together to create a shared care plan and an identified lead care coordinator, and
3. Use that care plan to provide ED diversion services and connect patients with appropriate community-based, outpatient behavioral health treatment and community services.

Background

Between 2021 and 2024, the Camden Coalition worked with four regional health systems (Cooper University Health Care, Inspira Health, Jefferson Health, and Virtua Health) and two Certified Community Behavioral Health Clinics (CCBHC) (Oaks Integrated Care and Acenda Integrated Health) to design, launch, and test the Pledge to Connect model within six EDs across five counties in the South Jersey region. This initiative was focused on connecting patients with BH needs from the ED to outpatient BH and community services, with the ultimate goal of connecting patients to the care they need in the community to prevent future ED visits.

This multi-year demonstration project built on the CCBHC model defined through the Excellence in Mental Health and Addiction Treatment Act of 2021, combined with the Camden Coalition’s experience working with partners to strengthen transitions of care. The work also began soon after the 2019 – 21 South Jersey Community Health Needs Assessment declared BH a top priority in the face of the rising number and urgency of individuals with mental health and substance use needs across the region.

In 2024, the Camden Coalition data team conducted a retrospective, exploratory analysis of the pilot data from 2022 through 2024. This evaluation of the pilot across EDs showed that embedding CCBHC BH navigators into the ED proved more effective than telephonic workflows for engaging patients and supporting them in scheduling and attending follow up outpatient appointments. The program also supported patients in getting connected to care quickly: patients engaged had a median time of five days between their ED visit and intake appointment, and one-third of referred patients attended their intake appointment within three days of ED discharge. The analysis also found that there was equitable engagement throughout the workflow – patients’ age, race and primary diagnosis had no correlation with their likelihood to engage, accept services, or attend an appointment. The only exception was that women were more likely to engage and ultimately attend a follow-up appointment.

However, our evaluation also showed that additional referral and engagement strategies are needed to improve engagement with patients with more frequent ED and hospital utilization, especially those with multiple complex needs. In other words, relying on the busy ED team to identify and refer patients during a visit was not the best place to engage some patients. Specifically, our demonstration work found that patients referred to Pledge to Connect often had infrequent use of ED (an average of 1-2 visits per patient) and inpatient care (an average of less than one visit per patient) in the three months prior to referral. Those with more frequent and recent ED and hospital utilization, as well as those who exhibited suicidal ideation at the time of their emergency department visit, were less likely to be engaged in the Pledge to Connect program.

Over the course of the project, we were also able to gather and share implementation lessons learned. In 2023, the Pledge to Connect program was selected as one of 10 national winners in the Substance Abuse and Mental Health Services Administration (SAMHSA) Behavioral Health Equity Challenge in recognition of how the program reached underserved populations.  In 2024, we published a Pledge to Connect Implementation Guide to share data and lessons learned from the demonstration period.

Project design

The current pilot phase has three main components: the continuation of quarterly regional case conferencing to discuss cases with the highest complexity; regional triage that deploys intensive case management for individuals utilizing EDs at multiple health systems for BH-related care; and BH data integration into the HIE to support care coordination efforts.

Regional case conferencing: Quarterly convenings across systems to coordinate patient care

As a first step toward engaging unreached patients with complex needs, we began convening all of the Pledge to Connect health system and CCBHC partners in early 2024 to review regional data, discuss shared lessons learned and continuous improvement, and case conference around shared patients.

This initial step came from a recognition that patients were getting referred into the Pledge to Connect workflow from multiple EDs, yet there was no existing mechanism for teams to develop shared or coordinated plans of care across different health systems. The CCBHC navigators were also reporting that there was a small subset of patients who were frequently visiting the ED but were challenging to engage in the program due to social barriers such as a lack of phone or instable housing.

In quarterly complex case conferences, partners discussed lessons learned across their pilots and created shared care plans for patients who were frequently using EDs for BH-related needs across multiple health systems.

The patients highlighted in the complex case conferences were identified through the Camden Coalition Health Information Exchange (HIE) and with input from our partners. First, we used the HIE to find patients who had visited multiple health systems for a behavioral health issue within a six-month period. After identifying a list of patients who met these criteria, we worked with our partners to identify 1-2 patients who could benefit the most from a coordinated and shared care plan across health systems. After selecting the individual, we worked across partners to gain that individual’s consent for their case to be discussed, including Part II CFR data, which adds extra protection and confidentiality to a patient’s information related to substance use disorder and treatment.

With this consent, the Camden Coalition team created a patient summary from information available in the Camden Coalition HIE. During the case conference at the regional convenings, partners had the opportunity to add their input and perspective around their experience with the patient, including the patient’s expressed goals for themselves, strategies that had worked well for supporting them, and barriers to care.

A key component of the shared care plan was that we identified one primary contact for each patient – usually the CCBHC navigator – and an action plan for how best to support the individual if and when they came to any of the EDs across health systems. We also identified and named key champions from each health system to help communicate the shared care plan and ongoing case updates with their teams.

The goal was to conduct an intensive, in-person review of a small number of cases to better support individuals within the Pledge to Connect program with the highest needs, and to develop new hypotheses about the best ways to manage care for people seeking BH help across multiple EDs.

Results

Between February and June of 2024, shared care plans were created for four patients. The care plans enabled three of the four patients to connect with the CCBHC navigation team, resulting in steep declines in ED use after intensive case management and communication across health systems. This intensive case management was possible because of the shared care plan in place, as well as the trusting relationships developed between the CCBHC navigators and the ED teams as part of the multi-year Pledge to Connect program. For example, one patient with 95 ED visits in the year prior to case conferencing had only one ED encounter in the three months following connection to the navigation team.

Partners noted that without the Camden Coalition HIE and structured case conferencing, they lacked the ability to see real-time, cross-system ED visits for BH-related needs, hindering coordination outside of Pledge to Connect. As one ED provider said: “We have probably 20-50 patients that drive regional costs between hospital systems. [The Pledge to Connect complex care case conferencing] was a concrete step towards standardization of care across numerous care paths.”

Regional triage: Coordinated case management for individuals across systems

Regional triage aims to expand the success we achieved through complex case conferencing to a larger cohort of patients with complex needs and frequent ED use across multiple regional health systems. By designating the CCBHC case manager as the primary point of contact and using a shared care plan across health systems, our hypothesis is that this workflow (see Figure 1 on page 4) will increase connection to outpatient, community-based services for these patients, which will lead to decreased ED visits for patients with at least four ED visits in the past six months.

The Camden Coalition team will identify patients through the Camden Coalition HIE who have visited multiple health systems within the past six months for behavioral health needs based on diagnoses linked to at least one visit. The patients will be randomized to intervention or control arms, allowing for an evaluation of outcomes at the end of the regional triage pilot. Patients randomized to the intervention arm will be assigned to the CCBHC team, adjusting and scaling for growth as capacity allows. Patients randomized to the control arm will receive the standard of care support offered by each hospital. Because this is a pilot, there may be adjustments to this process as we learn from the early stages of this work.

Camden Coalition and CCBHC staff will review new patient cases during a biweekly care planning meeting. The CCBHC case manager will then receive an email alert through the Camden Coalition HIE when an assigned patient visits a designated ED or is admitted to any hospital within the four participating health systems. Consistent with the Camden Coalition’s original care management model, the CCBHC case managers will use HIE email alerts to notify them when assigned patients go to the ED or are admitted, and will attempt to engage patients in-person while they are in the hospital.

As the CCBHC teams engage and work with patients who have been assigned through the HIE, they will document their care in the shared care plan. Regular updates will also be sent out by the Camden Coalition and CCBHC case manager to designated care team members such as physicians or social workers within the EDs at each health system to enhance care coordination across systems and reinforce the CCBHC case manager’s role as the patient’s primary contact.

The Camden Coalition and CCBHC Pledge to Connect teams will use the bi-weekly care planning meetings to provide updates on shared care plans and discuss any challenges and barriers within the workflow to support continuous improvement.

The quarterly regional case conferences will continue to be used to create more in-depth shared care plans for individuals engaged in the regional triage workflow who would benefit from enhanced collaboration between the health systems.

Behavioral health data integration

Integrating BH data into the Camden Coalition HIE, which will be happening in parallel with the regional triage pilot, is another critical tool for improving care coordination for patients with BH needs. Due to the complexities of patient consent and data management, BH data is not typically shared between health systems and outpatient behavioral health providers, creating a significant barrier to effective care. Between 2023 and 2024, the Camden Coalition worked to integrate BH data from one CCBHC (Oaks Integrated Care) into the Camden Coalition HIE, laying the groundwork for broader implementation.

The integration is in process, with live data currently flowing into the HIE’s test environment. We are pursuing the technical requirements needed to secure BH data while maintaining accessibility of non-BH data to facilitate data sharing; we anticipate the integration of BH data into the HIE will be live in early 2025.

The lessons we learn will be compiled into a BH data integration guide to encourage other South Jersey BH providers to contribute data to, and utilize, the HIE. Having multiple partners across the region contributing BH data into the Camden Coalition HIE will be a significant contribution to the care coordination of patients in South Jersey and will serve as a model for HIEs state- and nationwide looking to pursue BH data integration.

The pilot will be active through 2025.