Service Spotlight: Bridging Team

Cardinal Innovations Healthcare is one of three LME/MCOs chosen as a pilot site for the NC Transition Bridging Team Initiative. The pilot is funded by a grant from the Division of Medical Assistance. The Money Follows the Person (MFP) demonstration project helps eligible people move from long-term care facilities into their own homes and communities with proper supports.
People moving into the community from long-term care facilities may face unique challenges. To address those needs, Cardinal Innovations and The SPARC Network, LLC have formed a Transition Bridging Team to improve coordination of care. Transition Bridging Teams support people who have complex clinical needs and who are moving from a facility into the community, consistent with the Home and Community-Based Services Final Rule. The HCBS Rule allows:
  • Access to the benefits of community living
  • Delivery of services in the most integrated setting
  • Choices about where to live
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The Bridging Team is made up of multiple partners with a focus on coordinated strategies and creative thinking to ensure successful transitions. The SPARC Network, LLC team includes a Qualified Professional, Licensed Psychologist and Educational Specialist. The Cardinal Innovations team includes a MHSUD Care Coordinator and IDD Care Coordinator,
Nurse Consultant, Psychiatrist and Clinical Director. NC Start also will provide consultation, training and support during the pilot.
People who may be eligible to participate are members with a dual diagnosis of IDD and MHSUD or a diagnosis of IDD with significant behavior challenges and members moving out of a facility such as a Psychiatric Residential Treatment Facility (PRTF) or a Developmental Center Specialty program. Members who have experienced intensive treatment such as PRTF or specialty program more than once with unsuccessful outcomes may also be eligible.
Our members are already achieving success through the Bridging Team. In October 2017, a youth was discharged from PRTF into a Therapeutic Foster Care Placement and referred to the Bridging Team. The individual is currently diagnosed with Disruptive Mood Dysregulation Disorder (DMDD), Attention Deficit Hyperactivity Disorder (ADHD) combined presentation, Disinhibited Social Engagement Disorder, and mild Intellectual Disability.
The member has a history of DSS involvement as well as a criminal investigation due to allegations of abuse from a family friend. In addition to placement in a PRTF, the child also has a history of multiple psychiatric hospitalizations and has been placed multiple times with various family members. The member has been doing well in foster placement with support from the Bridging Team. The Bridging Team has supported the member and foster parent by making sure that community interests are being met as well as assisting with the implementation of behavioral intervention strategies. The Bridging Team has also been able to support the member in meeting academic needs by working with the day treatment program. Through weekly communication with the day treatment staff, the team has been able to make observations and recommendations that help the staff better meet the member’s unique needs.
A huge highlight is that the member has not needed any physical interventions/restraints since discharging from the PRTF. The member has improved in the ability to stay focused and complete class assignments. This has been accomplished by redirections and verbal prompts, as well as positive reinforcement.
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