New Team Supports Patients Transitioning Home After a Mental Health Crisis

What happens to patient outcomes in mental health when we build an entire team to support them after discharge?

For parents and families facing an acute mental health crisis, the moments after a discharge are critical. The right care approach can make all the difference, easing burdens, giving families concrete next steps and setting children up for success in their healing journeys. By contrast, when families don’t have access to the kind of wraparound services being implemented at Children’s Hospital Colorado’s Pediatric Mental Health Institute, they can face a genuine barrier to healing that can lead to emergency room readmission within just days.

It’s something Lauren McCarthy, PhD, LCSW, an assistant professor at the University of Colorado School of Medicine, has seen time and time again.

“I have done interviews with families about their experiences navigating the mental health care system, and so consistently they said things like, ‘When my kid reached that high acuity inpatient level of care, I felt so lost,’” Dr. McCarthy recalls. “They’d tell me, ‘I didn't know what was going on. I felt really cut out of decision-making.’”

Factors like these can contribute to high mental health emergency readmission rates. To address these concerns, says J. Jonathan Benitez, LPC, LMHC, Behavioral Health Manager of Care Transitions, the Pediatric Mental Health Institute has been working diligently.

Over the course of 11 months, the team developed a new initiative to target these struggles through the creation of a new team focused on mental health care transitions. Launched in September 2024, the team, which includes education specialists, health navigators, care coordinators, family peer support partners and many others, has reached more than 150 patients and families.

“It's all about that right place, right care, right time, and we were missing it when we were asking families to do it on their own when they go back into their community,” Benitez says. “For many reasons, two to four weeks later, discharge plans can fall apart. Now, a family doesn't have to navigate that complex mental health system alone. We extend ourselves to navigate and support you, so you stick the landing wherever you're going. ”

How the care transitions team works

The care transitions team works through a referral system. Any clinician across the hospital can refer a patient to the team, and from there, a placement specialist will help determine whether the patient meets the eligibility criteria. These criteria include having two or more hospitalizations or behavioral health emergency room visits within four months, being discharged without a clearly defined aftercare plan, seeking care for mental health for the very first time and others.

If a patient meets one or more of these criteria and consents, the team assembles. Each patient and family goes through a screening questionnaire that helps the team’s placement specialists understand which supports they will need. That might mean getting referrals for parents who have their own mental health needs, tapping in an education specialist to help with school avoidance or adding a health navigator to the team to help families overcome transportation concerns or food insecurity.

Depending on each family’s unique needs, the team develops a plan and provides attentive care for anywhere from 60 to 90 days. That can include regular phone calls or visits, help coordinating referrals and support with return-to-school plans. The results have been promising. For children served by this program, early trends suggest that emergency readmission rates are lower, indicating more successful transitions back to family and home.

“I've been at a lot of organizations where innovation is a very scary thing and people do not want to do it. They don't want to change,” Benitez says.  “Here, I was told by my leaders, ‘This is why we brought you in.’ That's been the big difference. We went from nothing to everything that we have now, and we have a very beautiful, bright future ahead.”

The power of family peer support partners

One of the most unique elements of the team is its family peer support partners. Each family peer support partner was hired because they have personal experience navigating the mental health system, either for themselves or as a caregiver. Every single patient that works with the care transitions team is assigned a family peer support person.

The family peer support team members are all trained by the Family-Run Executive Director Leadership Association, or FREDLA. The goal of the training is to teach techniques that empower the families, center their needs and help them learn to advocate for themselves. To do this, family peer support providers remain in touch with families through phone calls, virtual visits, texts and in-person time, offering an ear and a gentle nudge when needed.

“There's nothing like having a family speak to somebody who's gone through it who can use their story to establish hope and let them know you're not going to do it alone — we’re here with you,” Benitez explains. “These are not volunteers but paid professional staff. We have five of those peer support people, and they've been doing an excellent job.”

Wrapping in mental health research

Because the care transitions team is grant funded through the next year, all its services are currently free. The grant funding not only allows for increased access to such vital services, but also for thorough research that measures its impact.

This research has allowed Dr. McCarthy to provide real-time feedback and information to Benitez, who can then implement strategic improvements. For example, during the early weeks of the pilot, provider surveys clued the team in to challenges with space. The team reported that it was sometimes difficult to find dedicated areas for private conversations with families — something that was quickly remedied thanks to the inclusion of researchers.

Over the course of the next six months, Dr. McCarthy and other researchers are working to measure a few key indicators of success: adoption, implementation and maintenance. Through surveys and interviews with families and providers, the team hopes to understand how comfortable clinicians feel making referrals, how satisfied families are with the experience and whether burnout becomes an issue with team members.

Such investigations are designed to help the program thrive beyond the terms of its grant, but also to inform other researchers and hospitals across the country who might be implementing a similar approach to care. What’s more, it creates a better pipeline between the research bench and the bedside.

“I think sometimes there is a research-practice gap,” Dr. McCarthy says. “Having research involved from the beginning of a program helps bridge that gap and improve the quality of both our research and our care.”