Bridging the Gap in Behavioral Health Care

ANN ARBOR – St. Joseph Mercy Ann Arbor is using an innovative care model to bridge gaps in behavioral health services – a growing need across the country and especially in Washtenaw County – to better serve adults with serious mental illness.

The Transition Clinic was originally designed to transition adults from an acute setting into outpatient care. National studies suggest that up to half of all patients discharged from a behavioral health hospital or inpatient facility are readmitted within one year due to a poor transition to outpatient services which often have delays due to high volume. After being discharged from the hospital, individuals with persisting mental illness are especially vulnerable, and are more likely to relapse or engage in self-harm behaviors. Studies show that for patients with serious mental illness, brief, intensive outpatient case management can be an effective bridge from inpatient to outpatient behavioral health care.

Stephen Pinals, M.D.Dr. Stephen Pinals, system chair for the Department of Psychiatry at St. Joseph Mercy Ann Arbor and Livingston, states, “This program has been so successful in helping to keep our patients out of the hospital that we’ve decided to open up our access to local primary care groups and community partners.  By providing psychiatric assessment and evaluation for patients who are unable to wait two to three months for an outpatient appointment, we’re now able to avoid unnecessary emergency room visits and hospitalizations.”


Most patients referred to the Transition Clinic will be seen within three to seven days of referral. St. Joe’s program provides a range of short-term services such as focused case management, crisis support, medication assessment and brief psycho-therapeutic treatment, and collaborates closely with local primary care clinics for highly coordinated care.

Patients referred to the Transition Clinic must be ambulatory and medically stable; have no history of violence or traumatic brain injury; seek treatment voluntarily and must be at least 18 years of age. The clinic will do a baseline assessment of patients before recommending a referral to an outpatient behavioral health provider or referring back to primary care providers with further recommendations.

The Transition Clinic is co-located with the Adult Partial Hospital and Greenbrook Recovery Service at Huron Oaks, and allows convenient access to those programs as needed.

Dr. Pinals said, by providing coordinated behavioral health care, the Transition Clinic can help divert patients from unnecessary ER stays or inpatient hospitalizations while ensuring they get seamless mental health care. “Our goal is to provide easily accessible and high quality clinical care for individuals with mental illness.  We generally see patients 2-3 times before referring them back to their primary care providers with specific recommendations or on to further specialists for ongoing care.”

Providers can call the Transition Clinic referral number at 734-712-5762 and learn more about the range of Behavioral Health Services at St. Joe’s Ann Arbor at www.stjoesannarbor.org/behavioralhealth.

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