Continuity of care is the process by which patients and their team of providers are cooperatively involved to help coordinate health care management and ensure access to effective care across settings as patients’ conditions and needs change.

This process reflects Evernorth Behavioral Health’s understanding of the complex interrelationship between emotional and physical factors, and the fact that mental health issues often complicate or present as medical illnesses. Conversely, medical problems may present with psychiatric symptoms. Your timely communication with your patient’s other health care providers is vital to ensuring continuity as they move within the care delivery system to receive necessary treatment.

To facilitate the sharing of information during treatment, behavioral health providers should speak with their patients about the importance of coordinating care and request a signed Release of Information (ROI), as required by law, from their patients. Appendix G of the Evernorth Behavioral Health Administrative Guidelines includes a sample release form and letter to support your communication with patients’ primary care providers (PCPs), other behavioral care providers, or any other relevant healthcare professionals. Additionally, you should document all verbal and written communication with any other care providers.

Communication expectations

For each patient, participating Evernorth Behavioral Health providers are expected to:

Obtain and document:

• Any other treatment providers the patient has (including name, address, telephone, and fax, if available, numbers).
• The required Release of Information form giving permission to exchange information with the patient’s other treating providers. Likewise, you should document a patient’s refusal to allow communication between providers.

Exchange appropriate clinical information directly with other providers in an effective and timely manner throughout the treatment regimen. With proper consent, facilities can contact PCPs or other providers upon admission and discharge. Outpatient providers are also expected to exchange appropriate clinical information directly with PCPs or other treating providers. At a minimum, communication should occur:

• After the initial assessment, including diagnosis, prescribed medications, initial treatment plan, and diagnostic tests that are recommended or ordered.
• When a patient is not compliant with treatment recommendations.
• When a patient’s condition is unstable.
• When there are clinically significant changes in a patient’s condition or level of care. This may include inpatient care, partial hospitalization, intensive outpatient treatment, comorbid medical and behavioral conditions, or new or substantial medication changes.
• At the completion of behavioral treatment. 

Disruptions in care and lack of timely communication about co-occurring care may result in delays in treatment and poor health outcomes for patients. Through communication and collaboration, continuity and coordination of care can be achieved and ultimately meet the needs of patients who are experiencing comorbid medical and behavioral conditions.