A strong family and caregiver support system is important to the continued treatment of mental health patients after they leave the hospital. In fact, it is critical in assisting with medication adherence to ensure consumers appear for their appointments with service providers, particularly during transition between inpatient and outpatient settings. However, when discussing family support systems, some physicians contest that less than half of consumers have an "adequate" social support system to meet their daily needs.

Because a strong family support system cannot be "manufactured" or bought through funding, it is important to focus on other controllable issues that can create a positive impact on the continuity of care for mental illness patients. A recent mental health study identified three factors that positively influence the efficiency of the transition process between inpatient facility discharge and intake with a community-based program.

These include:

• when communication occurs "within system"

• when computer systems/consumer records are shared

• when an ACT (or similar) team is involved

Of course, in addition to having a strong family and care support, there are other issues involved. Public policy and government funding are two particularly impactful issues. From a mental healthcare systems perspective, matters involving policy and financing issues impacting continuity of care can be conceptualized along two broad approaches:

1.) Building service coordination into the payment rates and expectations for certain services.

This approach is conceptually similar to what is referred to as Primary Care Case Management in some disease management or chronic care programs.

2.) Defining certain consultation and care coordination services as covered benefits.

Under the first approach, consultation and care coordination would be a defined benefit with its own billing codes and defined coverage limits, eligible providers, allowed situations, and limitations and exclusions. For example, situations where this might be applicable include: hospital discharge planning and short-term transition support; developmental transitions (e.g. child to adult); coordination between primary care and mental health providers; consultation with primary care; consultation with other professionals to implement treatment plans (e.g. schools, residential programs); clinical coordination among multi-disciplinary teams, especially home-based services.

Under the second approach, coordination of care is built into "programs of mental healthcare" or episodes of care. This concept is seen in current disease management models and chronic care models and can include: assertive community treatment, multi-systemic therapy, and Dialectical Behavioral Therapy (DBT). Hospital payment methods assume linkage with step-down, aftercare, and outpatient services, similar conceptually to Medicare Part A that covers hospital stays and 100 days of nursing home or home health rehabilitation as follow-up, when necessary.

Levels of communication between various clinicians and other staff in inpatient and outpatient settings can vary greatly, impacting continuity of therapy. Typically, there is very little communication between psychiatrists in inpatient and outpatient facilities and this applies as well to nursing staff in these two settings. The most frequent communications occur between inpatient discharge planners and outpatient intake coordinators. Three specific models of interaction between inpatient and outpatient facilities have been identified:

• "Push" Model: In this model, the outpatient setting is highly dependent on the inpatient setting and/or the consumer for receiving documents.

• "Integrated" Model: With this model, the sharing of resources provides a continuum of care for consumers, so there is never really a "gap" between discharge and intake.

• "Pull" Model: For this model, a member of the outpatient treatment team actively participates in the discharge process, which leads to the timely receipt of appropriate/relevant documents, as well as increased consumer participation.

Despite the link between positive consumer outcomes and continuity of therapy, it remains unclear, in many cases, how referrals are made throughout the system of care; how hospital and program admission criteria are developed and applied; how consumers are discharged from hospital settings and into the community; and who is responsible for their care. Data regarding who is going to hospital emergency departments for acute psychiatric care and why they are in that setting rather than in community mental health program are scarce, as are data about individuals who could be moved out of hospital emergency rooms if consumers were provided with better transition services or if appropriate acute psychiatric care were available in other settings. The same observation can be made regarding those individuals who could be moved out of state psychiatric hospitals if appropriate services such as care management, medication management, housing, and employment supports were available in the community. Obtaining these observations and data of this kind is a big and important step in ensuring a continuity of care for all mental illness patients.