The purpose of the Care Coordination Planning Team is to improve care coordination in the Greater Houston area for individuals with high utilization of emergency health services and criminal justice systems.
The initiative started when a client had been admitted to the Sobering Center 18 times in 5 months. On the 18th admission, we learned this individual had been transported by EMS over 80 times to 7 different hospitals in 8 months.
How it works:
- The group meets every quarter to discuss how to implement care coordination across the provider systems impacted by the high utilizer population.
- Collaboration between hospitals, jails, law enforcement agencies, mental and public health entities, government resources, and service providers.