Seamless Transition Committee: A Model for Providing Coordinated Care

Jay Morse & Heidi Radunovich, PhD

Creative Commons [Flickr, Veteran, October 4, 2008]
Creative Commons [Flickr, Veteran, October 4, 2008]
Veterans returning from combat deployment who are seeking health care can be faced with complicated treatment plans. One Veteran’s Affairs health care center has implemented a “Seamless Transition Committee (STC)” which allows for complex cases to be presented to a multi-disciplinary team for feedback and coordination of care. The STC is composed of leaders from a wide range of disciplines and includes: the chief psychologist; program managers; the suicide prevention coordinator; and the medical director of the Post-Deployment Primary Care Clinic. In a typical case, the STC team members would discuss the case background, establish treatment priorities, and agree to treatment recommendations. Review meetings are scheduled for one hour each week at the same time and location.

Results of the program evaluation conducted by Mallen, Schumacher, Leskela, Thuras, and Frenzel [1] suggest that this is a promising model. Over the 3 year study, 149 veteran’s cases were reviewed by the Seamless Transition Committee. Over 50% of the veterans in the STC program had at least 3 mental health diagnoses. The most common diagnoses included: (1) Depressive disorders (77.2%); (2) PTSD (62.4%); (3) Substance abuse (56.4%); (4) Anxiety disorder (44.3%); and (5) Personality disorder (20.1%). Over 40% of the veterans in the program were psychiatric inpatients at some time and over 60% participated in the facility’s Psychiatry Partial Hospitalization program (PPH).

A pre/post study analysis was conducted. Significant changes in service utilization were noted, including a significant decline in psychiatric hospitalization rates. Overall:

  • Visits to mental health clinics increased.
  • PPH utilization remained approximately the same.
  • Inpatient psychiatric hospitalization rates declined from 24.7% to 8.2%.
  • There were no significant changes in emergency room or primary care utilization rates.

The researchers noted that as veterans’ cases were presented at the STC, the veterans utilized outpatient services more often and used inpatient services less. The results of a staff survey indicated that the staff believed that veterans’ care was improved. These changes were attributed to expedited care received through the STC. The STC might provide a good model for other systems of care that wish to enhance collaboration among specialists, and provide more efficient care to patients.

References

[1] Mallen, M., Schumacher, M., Leskela, J., Thuras, P., & Frenzel, M. (2014). Providing coordinated care to veterans of Iraq and Afghanistan wars with complex psychological and social issues in a department of veterans affairs medical center: Formation of seamless transition committee. Professional Psychology-Research and Practice, 45(6), 410-415. doi:10.1037/a0037755

This post was written by Jay Morse & Heidi Radunovich, PhD, members of the MFLN Family Development (FD) team which aims to support the development of professionals working with military families. Find out more about the Military Families Learning Network FD concentration on our website, on Facebook, on Twitter, YouTube, and on LinkedIn.

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