Strengthening Transitions in Care: Supporting Behavioral Health and Substance Use Recovery

Posted by PHN Communications | August 11, 2026 | Featured News

Healthcare, writing and hands of doctor with clipboard for insurance, medical service or wellness. Hospital, clinic and person with paperwork, documents and forms for prescription or patient report

Timely follow-up care—a cornerstone of high-quality behavioral health treatment—offers opportunities to reduce readmissions, improve outcomes and support long-term recovery.

A range of clinical resources are available to aid in the delivery of comprehensive, patient-centered care for those with behavioral health and substance use diagnoses.

Behavioral health tools for primary care providers
Primary care plays a critical front-line role in identifying and managing behavioral health conditions. Access screening tools, treatment guidance and referral pathways to help integrate behavioral health into routine care.

Recovery, resiliency and empowerment toolkit
This toolkit provides links to a host of resources, including recovery organizations and support services, to guide and empower patients with complex behavioral health and substance use needs and concerns. 

Medication-assisted treatment (MAT) resources
MAT is a key component of recovery for many individuals with substance use disorder. Evidence-based strategies include effective pharmacologic interventions, such as Medication for Opioid Use Disorder (MOUD) and Medication for Alcohol Use Disorder (MAUD), alongside counseling and care coordination. Explore clinical guidance, best practices and implementation resources to support safe prescribing and ongoing patient engagement.

Coordinating Care for Complex Needs

Some patients may require more intensive support to successfully transition to outpatient care. Complex case management programs can assist with care coordination and appointment scheduling, as well as address social determinants of health that may interfere with follow-up. See “Featured Resources to Address Behavioral Health Needs” for more about our programs, including referral pathways and patient eligibility criteria.

Practical strategies

  • Schedule follow-up appointments prior to discharge whenever possible
  • Use telehealth options to reduce access barriers
  • Engage family or support systems in discharge planning
  • Coordinate with behavioral health specialists and community resources
  • Leverage care managers for outreach and appointment reminders

Need more help?

Your partnership plays a crucial role in ensuring continuity of care. For support, contact Provider Services: 1-877-842-3210.