After Care Recovery

Care coordination, whole-person support and improved access to care after a crisis

We understand that a crisis is often just the beginning of a need. Our After-Care Recovery service is post-crisis telephonic outreach assistance designed to provide transitional care coordination to those who have experienced a behavioral health crisis intervention. Research shows that continued communication regarding how, where and when to seek further care is key to improvement in crisis situations.

Led by a clinician, our specialized team’s initial goal is to connect within 48 hours after the crisis episode with the individual’s care provider to ensure coordination of care is streamlined. The clinician conducts a post-crisis needs assessment that serves as the foundation of the after-care intervention strategy. From there, outreach calls are scheduled and executed as outlined in the plan. As a means of continued safeguarding, clinical and peer recovery support is provided until a connection to ongoing care services is made.

We also bring another level of expertise to after-care through culturally-specific support services. For example, to reach American Indians, we work with Tribal Support partners in Native American tribes to offer peer support and promote recovery concepts. Both clinical, peer and family support representatives are able to provide information about behavioral health topics and community referrals – knowing they have the resources and backing of our team.

  • Facilitating entry into behavioral health services based on referrals from primary care providers.
  • Post-discharge outreach to persons with psychiatric diagnoses.
  • Arrangement of timely behavioral health intake appointments upon referrals from hospitals.
Studies show that about 25% of all U.S. adults have a mental illness—and nearly 50% will develop at least one mental illness during their lifetime.

This outreach assistance helps coordinate care after a behavioral health crisis, including need assessment, after-crisis care planning and transitional support.

Client Benefits Include:

  • Coordination of care until the individual starts services or re-engages in ongoing behavioral health services.
  • A team with a combination of disciplines with nursing, social work, counseling and more that provides a multidisciplinary approach and enables triage of comorbid medical conditions by RNs.
  • Care coordination that is required for patient-centered health home models.
  • Prevention of ER visits and inpatient admission through telephonic triage.
  • Actionable, timely and easy-to-use reports and results.
  • Improved risk management.
  • Specialized skills in serving American Indian populations.
  • Experience serving both urban and rural areas.
  • The ability to provide whole person crisis care.
  • Customized, seamless service.
  • Assurance of accurate and clinically appropriate care advice.