Introduction: Social determinants of health are defined by DHHS as the “conditions in the environments… that affect a wide range of health, functioning and quality-of-life outcomes and risks” (ODPHP, 2024). Evidence supports the bidirectional connection between social determinants of health and mental health outcomes (WHO, 2022). In 2022, the Ohio Department of Mental Health and Addiction Services initiated the Access to Wellness (ATW) program with the goal of providing recovery support for long-term wellness in multi-system adults with Serious Persistent Mental Illness (SPMI), including people with homelessness. The funds, which are used to address social determinants of health, provide assistance with housing, emergency, basic needs, and transportation. Though this program has been successful in obtaining recovery support for homeless individuals who are linked with community providers, its success has been limited in patients presenting to the emergency department (ED); in the first year, only 2% of patients referred from the Riverside ED successfully received the funding. The majority of these ATW referrals were lost to follow up largely due to barriers such as lack of transportation and means by which to communicate with ATW staff. The objectives of this study were to 1) increase the number of ED patients referred to the ATW program who successfully receive recovery support funding 2) prove the value of a bridge case manager in optimizing outcomes for patients who present to the ED with mental health crises and housing instability.
Methods: Beginning in year two of the ATW program, a full-time bridge case manager was placed in the Riverside ED who met with patients on arrival to the ED and followed them post-discharge, providing assistance with transportation and other daily needs while maintaining communication with the patient through the care coordination meeting required for funding dispersal. For patients with established case managers, the bridge case manager served as a patient advocate and liaison, while providing full case management services for patients who were not previously linked in the community.
Results: Following implementation of a bridge case manager, over the following year, 15 of 69 referred patients successfully received funding, representing a nearly 20% increase in access to funding. An additional 17 patients attended the initial care coordination meeting, remain linked with the program, and are in the process of receiving funding.
Lessons Learned: Numerous barriers are faced by homeless individuals with SPMI who present to the ED with mental health crises, and to successfully improve social determinants of health for this patient population, these barriers must be addressed. Utilization of a bridge case manager was imperative to the the success of a state-funded recovery support program for emergency department patients with SPMI and housing instability.
Learning Objectives:
Educate on possible intervention to improve patient's access to resources in the community
Provide education on impact on social determinants of mental health
Provide education on interdisciplinary care with social work and other mental health agencies
