211 Care Coordination

The 211 Care Coordinators immediately begin connecting hospital staff and patients to available, conveniently located behavioral health services. 211 Care Coordinators follow-up to ensure a successful placement and update the electronic record to close the loop with discharge planners.

All emergency medical facilities in Maryland, including emergency departments that are free-standing as well as those that are hospital-based.

Patients experiencing a hospital overstay due to behavioral health needs or barriers to discharge should be referred to 211 Care Coordination. This includes eligible patients in emergency departments and adolescent inpatient behavioral health units. 

Referrals should be submitted even when the hospital is managing discharge planning or placement efforts internally. In these cases, hospitals may select Data Only, allowing the overstay and associated barriers to be documented without requesting active care coordination from 211. 

Patients who need additional support may be referred for active care coordination to assist with placement, discharge planning, and connection to appropriate behavioral health and community-based services.

Our statewide resource database has:

• substance use resources residential
  facilities, withdrawal management programs, medication management for opioid use disorder, crisis walk-in centers, recovery residences, helplines, telemedicine providers, and support groups
• mental health resources
  crisis intervention, support groups, helplines, partial hospitalization programs, day treatment programs, case
  management services, psychiatric rehabilitation programs, mobile-assisted treatment services, and assertive community treatment providers

As soon as possible following the initial psychiatric evaluation but no later than 48 hours after the patient arrives at the facility. Consent should be obtained prior to making the referral. However, referrals must still be made (without Protected Health Information) for patients that do not provide consent.

Consent to release information to the 211 program should be obtained prior to making the referral. However, referrals must still be made for patients that do not provide consent. In these cases, protected health information (PHI) is not collected.

A patient may need additional care coordination if they are not connected to adequate and appropriate behavioral health services, or if barriers are preventing discharge or placement. Even when services are already in place, additional coordination may be helpful to address changing needs, connect systems, or support a safe and appropriate transition from the hospital.

Not necessarily. If a patient is being admitted from the ED to an inpatient bed without delay, a referral may not be needed. However, if the patient's placement has been delayed and they meet the criteria for a hospital overstay, a referral should still be submitted for data collection, even if active care coordination is not needed. 

Hospitals will receive additional support with discharge planning and connecting patients to behavioral health resources. The additional data and information collected as a result of this regulation will also be used to inform policy and capacity needs.

No. Hospitals are still obligated to refer youth at risk for hospital overstay to the Local Care Team for interagency care coordination, per the December 16, 2020 “Universal Hospital Discharge Planning Protocol for Youth with Intensive Needs.” The LCT referral form and a directory of LCTs in Maryland are available online. A link to the LCT referral form is also included in the 211 Behavioral Health Care Coordination Program referral for convenience.