Preparations at MCES are underway for the launch of a new program that will send psychiatric RNs into the community to follow up with recently discharged patients.
The "Community Continuity-of-Care RN Program" will begin this month and feature eight MCES registered nurses who will follow 50 patients after their discharge from inpatient treatment. Patients will be selected to participate in the program according to an established criteria that focuses on recent re-admissions, diagnoses, housing situation, family support and other factors. Participating individuals must have been readmitted to MCES within 30 to 60 days of discharge at some point within the last twelve months.
Program participants will receive a visit from an MCES RN within 48 hours of their discharge and one visit per week for one month. After that, they will receive one telephone check-in each week for another month. To determine program efficacy, readmission rates for the 50 participants will then be compared with those of 50 individuals who also meet program criteria but were not selected for the home visits. As the main goal of the program is to prevent unnecessary re-admissions and promote more successful community integration, RNs will be encouraging participants to engage with outpatient providers, advocate for themselves and proactively address issues in the community that may otherwise have resulted in re-admission to the inpatient setting.
Participation in the program will be voluntary. RNs will begin making visits in the Norristown area to patients who are being discharged to outpatient services with Central MH-MR. The program will be in place for one year and results will be published on MCES’s website, through social media, as well as in MCES’s annual report.
Major funding for this program is being provided through grants from the van Ameringen Foundation and the Dr. H. Glenn Sample, Jr. Memorial Foundation, administered through PNC Charitable Trust