Continuity of Care Strategic Planning Guidelines

TABLE OF CONTENTS

  • Section I: Purpose
  • Section II:  Definitions
  • Section III:  Elements of the Continuity of Care Plan
  • Section IV: The Continuity of Care Strategic Plan Process
  • Section V:  Format for the Plan Document
  • Section VI:  Modification of the Plan

  • Addendum A:
    Expectations for Pre-admission Screening of Persons Referred to Inpatient Psychiatric Services

Section I: Purpose

The intent of the document is to clarify how DHS/DMH resources can be used in a coordinated way to minimize barriers between and among inpatient, outpatient, and emergency service providers in the local community. Studies that looked at continuity of care and consumer outcomes conclude that there is a strong relationship between well-coordinated elements of consumer care and positive outcomes. Data further suggests that consumers and providers report a greater job satisfaction when such systems are in place.

Section II: Definitions

Pre-Screening - Refers to the active evaluation of an individual in crisis after presentation at a community hospital emergency department in order to determine if a community-based treatment can be offered as an alternative to inpatient hospitalization.
Region Office - Refers to the local DHS, Division of Mental Health Regional Office. They are:

  • Region 1 North, 4200 North Oak Park Avenue, Chicago, Illinois 60634
  • Region 1 Central & Region 1 South, 1200 South First Avenue, Hines, Illinois 60601
  • Region 2, 750 S. State St. Elgin, Illinois 60123-7692
  • Region 3, 5407 N. University Street, Peoria, Illinois 61614
  • Region 4, 901 Southwind Road, Springfield, Illinois 62703
  • Region 5 (Metro East), 4500 College Avenue, Alton, Illinois 62002
  • Region 5 (Southern), 1000 North Main Street, Anna, Illinois 62906


State Operated Hospital (SOH) - Refers to any of the inpatient psychiatric facilities operated by the DHS/DMH.

Section III: Elements of Continuity of Care Strategic Planning

The local Region Office will be responsible for drafting a comprehensive Regional Continuity of Care Plan for the coordination of public mental health care. The Region Office shall collaborate with the Deputy Director of DMH Forensic Services, Deputy Director of the DMH Child and Adolescent Services, the DMH PATH Coordinator, as well as with other Department of Human Services Division executives to assure that local programs providing services to special populations are included in this plan. The Regional Strategic Plan is intended to be consumer driven, ongoing, responsive to needs and above all innovative and task oriented.


Continuity of care strategic planning will include, but not be limited to, the following:

  • Informational Continuity: Changes or trends in written documents (e.g., Consumer and Family Handbook), or verbal information about the local service system.
  • Contact Continuity: Changes to continuity once a person comes into contact with the service system as they encounter transition points, such as waiting lists, changes to intake process, etc.
  • Relational Continuity: Changes to an ongoing service relationship between the consumer and provider.
  • Management Continuity: Changes to parts of the system, such as adding an evidence-based practice, closing a system gap to avoid fragmentation of care, etc.

Section IV: The Continuity of Care Strategic Planning Process

The Region Office will be responsible for convening meetings, recording strategic plan proceedings, and publishing a plan document the group can reference throughout the year. Elements of the process are as follows:

  • Each Region Office will initiate a strategic planning process by sending a schedule of proposed meetings to the DMH contracted providers and other key stakeholders in their geographic area.
  • The COC strategic planning will be incorporated into the Region Service Network meetings.
  • The Region Office will invite representative stakeholders, such as:
    • Region staff
    • DMH Child and Adolescent Services staff
    • DMH contracted providers
    • Primary consumers and family members
    • State Hospital Managers
    • Community hospital managers
    • 708 Board representative(s)
    • NAMI representatives
    • Local FQHC representatives

Section V:  Format for the Plan Document

The strategic plan document will follow the below format and record continuity of care issues and problems, the proposed resolution, the person (s) responsible for the resolution, and the time frame for delivery or accomplishing the resolution.

Issue/Problem
Person(s) Responsible
Proposed Resolution 
Time Frame

Section VI:  Modification of the Plan

The Region Office will have responsibility for monitoring continuity of care in the local public mental health system and facilitating modifications to the COC Strategic Plan at regularly scheduled meetings throughout the fiscal year. If urgent situations unfold and cannot be held until the next scheduled meeting of the COC Planning Group, the Region Office shall:

  • Contact the appropriate provider and/or other stakeholder(s) that are affected by the issue at hand;
  • Fashion an appropriate resolution:
  • Modify the COC Strategic Plan document to reflect the resolution; and,
  • Notify all COC Stakeholders of the modification.

Addendum A: Expectations for Pre-admission Screening of Persons Referred for Inpatient Psychiatric Services

Any DHS/DMH provider that conducts pre-admission screening services is asked to conform to the following best practice:

  1. When performing a pre-screening, the pre-screener will:
    • Assess the individual's situation, and the community's resources, to determine whether options exist to inpatient hospitalization;
    • When options to inpatient hospitalization are determined to be absent, the pre-screener will assess whether there are options to state hospital referral (for example: hospitalization in a private hospital funded by the individual's existing insurance, hospitalization funded by a retroactive Medicaid application; hospitalization in a private hospital using DSH dollars for charity care); and,
    • Fully document the results of the evaluation.
  2. When the result of the pre-screening is a determination that a referral for inpatient hospitalization is necessary, the pre-screener will:

    If a pre-admission screening is conducted at a community site other than a hospital emergency room, coordinate the transportation of the individual to the nearest hospital emergency room and deliver a copy of the pre-screening assessment to the emergency room staff.
    If the pre-admission screening is conducted on a community hospital inpatient unit for referral to an SOH, the pre-screening will be included in the packet of required documents to facilitate the referral.
  3. When the result of the pre-screening is a determination that a referral for inpatient hospitalization is not necessary, the pre-screener will:
    • Provide the individual with a copy of the IDHS/DMH Consumer and Family Handbook;
    • Provide the individual with a written summary of recommended alternative services, including peer support;
    • Offer to a make an appointment for any recommended alternative services the individual wishes to access; and,
    • If an appointment is made, provide the individual with appointment information, including the date and time of appointment(s), the provider name, address, and general phone number, as well as any specific information that will enhance linkage, such as the name, title, and phone number of specific contact staff at the provider site.
    • If an appointment is not made, advise the individual of options for pursuing services on their own (e.g., provider local resource information, and/or direct them to the Consumer and Family Care Line @ 866-359-7953).