Transition Care Coordination Program

Kaiser Permanente designed the Transition Care Coordination Program for patients who are discharging from an inpatient detox or residential substance use treatment program as they are at high risk for relapse or readmission. All patients discharging from inpatient detox or residential treatment will be assigned a mental health care coordinator for care consultation and coordination. The goal of Transition Care Coordination is to ensure that the patient has the necessary outpatient treatment components in place and encourage the patient to follow through with the agreed upon discharge plan. Over time, the patient becomes more fully engaged in treatment and remains functional in their family and community roles. Relapse and readmissions may be reduced as well.

Transition Care Coordination is not counseling or psychotherapy. The program supplements the patient's current treatment team (primary therapist, psychiatrist, primary care physician). There is no charge for Kaiser Permanente members with mental health coverage.

The following services are delivered telephonically, within the context of a collaborative, empathetic, caring relationship, to help patients improve their level of functioning and decrease the impact of their symptoms:

  • Medication assistance
  • Additional resource support
  • Coaching
  • Care coordination to assist with disease management
  • Collaboration with members of the treatment team

Patients will continue in Transition Care Coordination until they are actively engaged in outpatient treatment or the patient is unable to be reached after multiple outreach attempts. In the event that the mental health care coordinator is unable to contact the patient, the outpatient treatment center staff is notified of the situation and is given the opportunity to do a second series of outreach attempts in an effort to engage the patient in treatment.

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