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The inTransition Program: Maintaining Continuity of Care Across Transitions

Overview. Created to assist service members receiving mental health services transition between health care systems or providersProvides voluntary one-on-one coaching to service membersDeveloped in response to the DoD Mental Health Task Force recommendation to Maintain continuity of care across t

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The inTransition Program: Maintaining Continuity of Care Across Transitions

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    1. The inTransition Program: Maintaining Continuity of Care Across Transitions Defense Centers of Excellence (DCoE) for Psychological Health (PH) and Traumatic Brain Injury (TBI)

    2. Overview Created to assist service members receiving mental health services transition between health care systems or providers Provides voluntary one-on-one coaching to service members Developed in response to the DoD Mental Health Task Force recommendation to “Maintain continuity of care across transitions” (5.2.2) Designed as a bridge of support for service members when: Relocating to another assignment Returning from deployment Transitioning from active duty to reserve, reserve to active duty, or returning to civilian life

    3. Program Goals Ensure continuation of treatment by assisting with the connection to the gaining provider Empower service members to improve their psychological and overall wellness Promote and encourage service members to consider healthy choices and model positive coping and adapting strategies

    4. Program Objectives Maintain engagement in treatment by motivational interviewing and follow-up Answer questions about mental health treatment modalities and techniques Identify situations or behavior that require direct engagement in mental health services and provide access to mental health resource

    5. Program Features One-on-one coaching with a Transition Support Coach (TSC) TSCs are licensed master’s or doctoral level mental health experts trained in motivational interviewing and coaching techniques Vendor: Magellan Behavioral Health, Inc. Ensuring continuation of care Community resource linkages Website: http://www.health.mil/inTransition

    6. Transition Support Coaches (TSCs) Clinical coaching expertise Motivational Interviewing SMART Behavioral Contracting Application of behavioral modification techniques Military cultural competency Issues related to relocations Family separation and readiness for deployment and transition to civilian life Post Traumatic Stress Disorder (PTSD) Traumatic Brain Injury (TBI) Depression and Anxiety Other health mental conditions, such as substance abuse and domestic violence

    7. Service Flow

    8. Program Process: Inbound Call

    9. Program Process: Confirm Participation

    10. Program Process: Confirm Participation

    11. Program Process: Initiate Coaching

    12. Program Process: Connect with Gaining Provider

    13. Program Process: Follow-up

    14. Community Resource Assistance The Transition Support Coach can assist service members with identifying community resources for issues related to the whole family such as: Military life Long periods of separation Relocation Being a military child Recovery systems for wounded service members and their families Military spouse education and employment

    15. Marketing and Outreach Activities Posters, patient brochures, provider brochures Targeted webinars by region, audience, topics Bi-weekly updates through listserv Conference participation American Forces Radio & Television Network PSAs Articles in DoD publications Social media partnerships with MHS, DCoE, Veterans Affairs, Wounded Warriors, Yellow Ribbon and more

    16. Program Evaluation Outcome indicators: Number of service members enrolled (FY2010 and reported annually thereafter) Average length of engagement per member (taken from yearly totals) Total number of enrolled service members with favorable satisfaction ratings relative to the total number surveyed (every 6 months beginning with program initiation) The total number of enrollees who remain in the program from initial enrollment to hand-off to gaining site/provider compared to the total number of enrollees in the program (FY2010 and reported annually thereafter)

    17. Program Benefits Improved continuity of care Improved follow-up of deactivating, separating and retiring service members with VA mental health services Empowered service members engaged in their own psychological health and overall wellness

    18. How Can You Help? Discuss inTransition with eligible patients Refer eligible patients to inTransition Encourage your peers to refer their patients to inTransition Communicate your experiences with the program to inTransition staff Remember that you retain primary responsibility for the patient until care has completely transitioned Join the inTransition Monthly Web Training Sessions "The Role of a Transition Support Coach” December 15, 2010: 11:00 a.m. – 12:00 p.m. (CST) Register: http://magellanhealth.na4.acrobat.com/e42041040/event/registration.html

    19. Contact inTransition Join our listserv! Email: intransition@tma.osd.mil Website: www.health.mil/inTransition Order Promotional Materials: http://intransition.contentcloset.com/ Call Toll-Free: 800-424-7877 Outside the US Toll Free: 800-424-4685 (DSN) Outside the US Collect: 314-387-4700

    20. Point of Contact George Lamb, LCSW Acting Division Chief Outreach Division Clearinghouse, Outreach & Advocacy Directorate Defense Centers of Excellence (DCoE) for Psychological Health (PH) and Traumatic Brain Injury (TBI) E-Mail: George.Lamb@tma.osd.mil Phone: (703) 604-5657

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