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 participant’s 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—based on the Naylor Transitional Care Model—was altered, with permission from the creators, to be more reactive to specific participant needs.

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 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.

The Teach-Back Method:

  • Uses motivational interviewing to learn a person’s feelings and needs
  • Asks person or caregiver to use their own words to explain their goals, needs, concerns, and questions
  • Checks for understanding and clarity by periodically asking person or caregiver to repeat back what was just learned or explained
  • Repeats explanation or develops new explanations until understanding is reached

How the New Model Works

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 are trained to implement the model 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 monitoring progress to make sure the health for each program participant is improving.

Just like many physical health problems and treatments encounter issues along the way, mental health treatments and programs like the Whole Person Transition Care Team may experience challenges. If a participant in the program has an issue affecting progress, they simply repeat a step until they are ready to move to the next stage. And even when someone does successfully complete the six-week program, they are never shut off from their team.

We never tell someone they are on their own and can’t contact us anymore,” said Shana Barus, Mental Health/Substance Use Care Coordination Supervisor for Partners. “They can always call us back-even if it’s just to tell us everything is good…we want to keep in touch with them and know their successes.

Six-Week Care Management Model:

  • Week 1 – Participants have at least two face-to-face visits and a supportive phone call each business day they are not seen face-to-face. When possible, one face-to-face visit will be on Friday to reduce the risk of weekend crisis and medication issues.
  • Week 2 – Participants have at least two face-to-face visits and get one supportive phone call.
  • Week 3 – Participants have at least one face-to-face visit and get two supportive phone calls.
  • Week 4 – Participants get at least two supportive phone calls and have no face-to-face visits unless necessary.
  • Week 5 – Participants get at least two supportive phone calls and will review their progress with the team. The participant and the team will start working on a smooth transition to normal, ongoing care coordination.
  • Week 6 – Participants have one face-to-face visit to recap progress and arrange final preparations for discharge or transfer.

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 an 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