Care Management Intervention to Address Determinants of Health for Individuals with Multiple Behavioral Health Readmission

Shari Hitchinson
Amy Herschell
Jamie Edwards
Irina Karpov
Deborah Wasilchak
Matthew Hurford
Peer-Reviewed Article
April 2022


Care management interventions for people transitioning from behavioral health inpatient care may be successful in decreasing readmissions if they address health-related social needs.


Many individuals receiving inpatient mental health or substance use disorder (SUD) care also have unmet social needs, which can lead to frequent readmissions. Community Care Behavioral Health Organization, a Medicaid behavioral health managed care organization (MCO) in Pennsylvania, developed a care management intervention that includes an interview between care managers and MCO enrollees and coordination with community-based care management providers to support transitions back into the community. This study evaluated the effectiveness of this intervention for individuals with both medical and social needs.


The care management intervention was associated with reduced readmissions to SUD facilities compared to the treatment as usual group, but was not associated with any change in readmissions to inpatient mental health care. Individuals who were readmitted were more likely to report having housing difficulties and being prescribed psychotropic medication and less likely to report having a recovery plan than those without readmissions.


Payers and health systems can improve the effectiveness of care management programs by improving navigation to help individuals receive the follow-up medical care and community-based services they need.

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