New Whole Person Transition Care Team

People facing big challenges to their mental and physical health are making huge improvements in their wellbeing through a new Whole Person Integrated Care program provided by Partners’ Mental Health/Substance Use Care Coordination Department.

On January 1, Partners launched the new program Whole Person Transition Care Team. The goal is to stabilize symptoms through proper, regular care and increased health literacy to reduce the number of crises, prevent returns or repeat visits to facilities, and instill healthy changes in participants’ lives.

The Whole Person Transition Care Team identified people living with chronic, severe mental illness and chronic health issues, like diabetes. The team also identified people with chronic, severe mental illness and excessive use of the emergency room (ER) or inpatient services, who displayed health risk factors, like a lack of regular preventive care, an ineffective support system, misuse or missed doses of medication, failure to show for appointments or lab follow-up, and poor nutrition.

Those willing to participate start the six-week evidence-based care management model. The model’s success is based on two ideas:

  • The participant is in control of setting goals, and making the plan to reach these goals, through informed consent and self-determination. The plans, called Whole Person Evaluation Action Plans, usually consist of two short-term goals and one long-term goal.
  • A team of health care providers and mental health specialists uses the Teach-Back Method to guide and support the participant through the process.

transition care

The new Whole Person Transition Care Team program is already yielding results, dropping one member’s ER visits from 2.5 times a week to once every two weeks.

Unlike people with typical care coordination who have a single person as a primary coordinator, the model uses a team approach. Currently, nine Care Coordinators trained to implement the model form teams from mental health counseling and substance use disciplines, nurses, and qualified professionals with a minimum of two years of mental health and substance use experience. The teams collaborate on education, treatment, and progress to make sure the health for each program participant is improving.

New Program Improving Health Results

Already, the program is making huge improvements in participants lives, and the changes start occurring relatively early in the program.

One person in the program made over 500 visits to the ER in three years. The person’s severe mental illness and symptoms related to Crohn’s disease were not under control. Once in the program, the participant and their transition team made a Whole Person Evaluation Action Plan. Among other items, the plan called for a standing appointment every two weeks with the primary care provider to maintain contact and treatment, and avoid returns to the emergency room. Since January, this participant has made only seven visits to the emergency room. Working with the Whole Person Transition Care Team, this person has gone from a visit to the ER once every 2.5 days to a visit once every two weeks.

Another participant lives with substance use disorder and diabetes. The person doesn’t get primary care, and when using substances, does not go to dialysis. With the assistance of the transition team, the person goes to dialysis three times per week and has not missed a session since starting the program. The person is now also connected with a dentist, an optometrist, and a podiatrist.

Currently, 42 people are participating in the program. Two individuals have successfully completed the program, and another 10 are waiting for their transitions.

To learn more about Whole Person Transition Care Teams, contact Colleen Kinslow at 828-323-8077 or, or Shana Barus at 828-323-8026 or

Member Navigator

What are my rights and responsibilities if I am in a 24-hour facility?

If you receive care in a 24-hour facility, you have some additional rights specific to your situation. You may also have responsibilities related to these rights. You have the right to:

  • Receive necessary medical care if you are sick. If your insurance does not cover the cost, you will be responsible for payment.
  • Send and receive unopened mail. You should also have access to writing material, postage, and staff assistance, if requested.
  • Contact and consult with the Concerns/Complaints/Consumer Rights Coordinator at 1-888-235-HOPE (4673).
  • Contact and see a lawyer, your own doctor, or other private professionals. You are responsible for expenses.
  • Contact and consult with your parent or legal guardian any time, if you are under 18 years old.
  • Make and receive confidential telephone calls. You are responsible to pay for all long-distance calls.
  • Have visitors at least six hours each day between 8 a.m. and 9 p.m. Two of those hours must be after 6 p.m. If you are under the age of 18, your visitors cannot interfere with school or treatment.
  • Communicate and meet with individuals wanting to communicate and meet with you. Your treatment team may supervise this meeting if they feel it is necessary.
  • Make visits outside the facility, unless your Person-Centered Plan states this is not recommended.

  • Go outside daily and have access to facilities or equipment several times per week for physical exercise.
  • Have individual storage space for your private belongings.
  • Keep personal possessions and clothing, except those prohibited by law.
  • Keep and spend a responsible amount of your own money.
  • Participate in religious worship, if you choose.
  • Retain a driver’s license unless you are prohibited to do so by a court of law.

Find out more on our Rights and Responsibilities web page, or call 1-888-235-HOPE (4673). If you feel your rights are being violated, you can make a formal complaint called a grievance. You can place a grievance by:

  • Calling 1-888-235-HOPE (4673)
  • Mailing your complaint to Partners Behavioral Health Management, C/o Grievances, 901 South New Hope Road, Gastonia, NC 28054
  • Emailing
  • Using our online feedback form
  • Approaching any Partners employee

Each option is confidential and secure. You also have the right not to be contacted by us, and not to have your information shared with others involved in the grievance. However, to serve you better and to effectively resolve the issue, we hope you will let us contact you, if needed.

In the Community 

QPR Suicide Prevention Training

Davidson LifeLine, in partnership with the Mental Health Association of the Central Carolinas, is offering  free Question, Persuade, and Refer (QPR) training through the Town of Davidson Parks & Rec, on Saturday, April 22, from 9-10:30 a.m., at Cove Church, 197 Langtree Road, Mooresville. QPR is 90-minute training, created by the QPR Institute for Suicide Prevention, to assist with suicide prevention education. QPR training provides three simple steps anyone can learn to help save a life from suicide. Just as people trained in CPR and the Heimlich maneuver help save thousands of lives each year, people trained in QPR learn how to recognize the warning signs of a suicide crisis and how to question, persuade, and refer someone to help. Please contact Lisa Johnson at or 704-881-4492, or Mike Hoffman at or 843-245-6189, for more information or to register.

Cleveland County Health Department Survey

The Cleveland County Health Department needs your help assessing community satisfaction with their services and operation. Please answer the questions in the online 2017 Community Satisfaction Survey or fill out the paper version and turn it in to Cleveland County Public Health Center, 200 South Post Road, Shelby, NC  28152. You can complete a survey until April 30, 2017. All responses are anonymous. Your input is vital as the health department strives to meet the public health needs of the residents of Cleveland County.

Free Youth Mental Health First Aid Training

Partners invites you to take a free Youth Mental Health First Aid Training to learn how to interact with and assist young people having a mental health or addiction problem. Training is on Thursday, May 25, from 8 a.m.-5 p.m., at First Plaza Building, First Floor Conference Room, 1985 Tate Blvd. SE, Hickory. Youth Mental Health First Aid is recommended for individuals over the age of 18 who regularly have contact with young people—teachers, coaches, social workers, faith leaders and other caring citizens are highly encouraged to attend. Please Register Online by Friday, May 19. For more information, contact Michael Smith at or 828-325-4693.

Family Fest 2017

Family Fest, sponsored by the Iredell County Adult and Children’s Collaborative, is a celebration of learning and health! The goal of Family Fest is to provide a fun day of learning for children and families and to raise awareness for the services and activities available to families in Iredell County. This year’s event will be held on Saturday, May 6, from 10 a.m. -2 p.m. at Statesville High School, 474 North Center Street, Statesville, NC 28677. Family Fest is a community collaboration. If you are interested in having a table at Family Fest, please complete the enclosed application form and return it to no later than Friday, April 28, 2017. There is no charge for your table.

Free Adult Mental Health First Aid

You are more likely to encounter someone in an emotional or mental crisis than someone having a heart attack. Learn how to help a friend, family member, coworker or neighbor in need. Get trained in Mental Health First Aid for free. Sometimes first aid isn’t a bandage, or CPR, or calling 911. Sometimes, first aid is YOU. The adult Mental Health First Aid course is appropriate for anyone 18 years and older who wants to learn how to help a person who may be experiencing a mental health related crisis or problem. Topics covered include anxiety, depression, psychosis, and addictions. Training is on Tuesday, May 16, from 8 a.m.-5 p.m., at Lincoln County EMS, 720 John Howell Memorial Drive, Lincolnton. Please Register Online or contact Karen Creech at 704-772-4314 or The registration deadline is Friday, May 12.

Bowling Night for the Hickory Brain Injury Support Group

The Brain Injury Support Group is having a social bowling outing on Tuesday, April 25, starting at 8 p.m. Bowling will be at AMF Colonial Lanes, 1951 US Hwy 70 SE, Hickory (across from Valley Hills Mall). Brain injury survivors can bring a guest and have shoes and two rounds of bowling paid for by support group funds. To RSVP, or for more information, contact Travis Glass at or at 828-781-0778. Also, check them out on

Behavioral Health Focus is published on the first and third Tuesday of each month and is intended to be a source of information for those working or interacting with behavioral health care in Burke, Catawba, Cleveland, Gaston, Iredell, Lincoln, Surry and Yadkin Counties. If you would like to contribute, contact Jeff Brucato at 704-884-2564 or Items should be submitted by Wednesday at 3 p.m. for the next week’s issue.

Volume 2 – Issue 20
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