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Improved mental health care through coordinated care


Kris Miller, L.C.S.W.
Kris Miller, L.C.S.W., and Intensive Transition Team program director


Steve Hefter, L.P.C. and Heather Hansen, L.P.C.
Washington County Health and Human Services Intensive Transition Team includes: Intensive care managers Steve Hefter, L.P.C. and Heather Hansen, L.P.C.

An older woman was being discharged from the hospital after attempting suicide. She needed to get into outpatient counseling within a day or two but nothing was available for three weeks.

A young woman, who had also tried to kill herself, also was about to be released but she needed housing so she could get the community services she needed.


"We stick with our patients, until they are connected to the right service." ~ Kris Miller, L.C.S.W., and Intensive Transition Team program director

These are the types of tough situations that Washington County's Intensive Transition Team (ITT) is good at solving. The team is a program of Washington County's Health and Human Services Department, with services provided by LifeWorks NW, a contracted provider. Washington County is part of Health Share of Oregon, a coordinated care organization that serves Oregon Health Plan clients in Clackamas, Multnomah and Washington counties. Soon, the ITT program will be expanded throughout the Health Share system.

"ITT makes sure people get connected to the right place; otherwise, they keep cycling through the emergency department," said Kris Miller, L.C.S.W., ITT's program director.

Patients get referred to ITT from hospitals, inpatient psychiatric wards, crisis centers and the police. Most of the 15 to 25 people the team helps monthly have mental illnesses. The ITT program is a short-term bridging service to support patients as they transition from the hospital, emergency department or crisis system to on-going community services.

"We help people with immediate support though counseling, intensive case management and care coordination. This can include identifying safe housing, transportation, medication – whatever it takes to prevent a hospital readmission – as well as to improve their health," Miller said.

The team provided support and counseling to the older woman until she could enroll with a mental health provider. After two appointments and several phone calls to remind her to take her medications, she went from suicidal to functioning. She now attends a support group and volunteers at a community center and a church.

The team found housing for the young woman and got her into Washington County's Transitional Age Youth Intensive Services for counseling and other help. She is now able to handle daily life and is attending community college.

Since the Washington County pilot program began in 2008, the county has seen a 26 percent decrease in hospital readmissions for the approximately 720 people it has helped. Now the program will expand to reach out to nearly every Health Share Oregon member who is hospitalized in an inpatient psychiatric unit and who isn't connected to a community provider.

"We stick with our patients until they are connected to the right service," said Miller. "It's very rewarding to help someone connect with the right support and move toward recovery and success.