Collaborative Bridges, a group of three safety net hospitals and three community mental health agencies in Chicago, Illinois, US, is introducing a model of care designed to improve mental and behavioural health on the city’s West Side.

The partnership aims to provide a seamless transition of care for patients as they leave the hospital and return to their communities.

The three safety net hospitals involved in the project are Hartgrove Hospital, The Loretto Hospital and Humboldt Park Health.

They have been partnered with Community Counseling Centers of Chicago (C4), Bobby E Wright Comprehensive Behavioral Health Center and Habilitative Systems respectively.

Under the new model, each patient will be assigned a care coordinator who will stay with them throughout their care journey.

The care coordinator will work with the patient to develop a personalised care plan that addresses all their needs, including mental health, substance abuse, housing, employment and transportation.

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Patients will also be given access to community resources such as peer support groups, job training programmes and affordable housing.

Collaborative Bridges executive director Patrick Dombrowski said: “We have an opportunity to create systems of care that are solution-focused and connected at a community level.

“When people seek hospital care for behavioural health and substance needs, it is often because they have inadequate community support in their lives. Collaborative Bridges is looking to change that.”

The project aims to help patients achieve long-term recovery and improve their overall health and well-being, as well as address the high rates of suicide attempts and lack of aftercare support that are common among patients with mental and behavioural health conditions.

Collaborative Bridges is part of the Illinois Department of Health and Family Services’ Healthcare Transformation Collaboratives (HTC), which is a state-wide initiative that aims to improve the quality and coordination of care for Medicaid beneficiaries.