Comprehensive Transition Planning During the Hospital Stay

RARE Mental Health Collaborative Learning Day

February 19, 2014

Dr. Paul Goering

VP Mental Health Clinical Service Line

Allina Health

What is Comprehensive Transition Planning?

Collaboration between patient, their family, and mental health providers to:

• Ensure patient’s needs are considered• Information is useful to patients and their

subsequent providers• Did we provide what is needed for success?

Different from discharge summary • Patient focus• Includes patient-specific recommendations

* From Recommended Actions for Improved Care Transitions Mental Illnesses and/or Substance Use Disorders ( RARE Campaign)

Comprehensive Transition Planning Key Recommendations for All Patients

Reason for Hospitalization and Transition Plan

Patient/Family Focused

Communicated at an appropriate level of health literacy

Medication management

Comprehensive Medication Reconciliation process

Dose, times, how to take, what to avoid

Where to obtain refills,

Indication for medication This has been a technical challenge!

* From Recommended Actions for Improved Care Transitions Mental Illnesses and/or Substance Use Disorders ( RARE Campaign)

Key Recommendations for All Patients (Continued )

Self Care - Nutrition- Exercise

Crisis Management Plan

Coordination and follow-up appointments - Engage patient to identify and arrange appointments

early during patient’s hospital stay- Coordinate visit with patient and their caregivers at

home to insure appointment can be kept

Transition plan written for patient Written at patient’s level of health literacy

* From Recommended Actions for Improved Care Transitions Mental Illnesses and/or Substance Use Disorders ( RARE Campaign)

Comprehensive Transition Planning Specifically for Patients with Mental Health Problems

• Coping Skills

• Nutrition/Exercise, diet

• Recovery goals and plan

• If acute of chronic medical condition with new depression or anxiety diagnosis, then schedule a mental health follow-up visit

• If there are physical health considerations and patient does not have a primary care providers, then engage patient and help arrange a follow-up visits

5

Are we providing what patients need for success?

6

Collaboration and Recommendations for Next Provider

Comprehensive Transition Planning: Collaborating with the Next Provider

• Barriers that may limit patients’ options post-hospital mental health care - Limited access to specialty providers

- Geographic

- Payment & insurance

Comprehensive Transition Planning: Collaborating with the Next Provider

• Anticipating patients discharge needs- Engage patient choice early

- Multidisciplinary Transition Conference to communicate among patient and Care Team

- Communicate the Plan and Recommendations immediately after discharge

- Timely follow-up appointments for priority needs

Strategies that Improve Patient and Next Provider Transition Planning

• Establish best practice and garner leadership support

• Changing the culture- Collaborate as team- Look beyond the current inpatient stay- Use patient survey results

• Performance Improvement Process- Establish measurable goals - Standardize Discharge Plan and Recommendations- Provide feedback on success

Strategies that Improve Patient and Next Provider Transition Planning

• Leverage Electronic Health Care Records where available (EHR)

• Allina uses Excellian (EPIC)- Pilot for standardize discharge summary for Mental

Health inpatients and recommendations to next provider- Automatic reminders and prompts for HBIPS- Automatic Routing to Next provider - Creates an After Visit Summary for the patient

These RARE ComplementHBIPS* Quality Improvement Measures

Rare Initiatives dovetail with HBIPS National Quality Improvement Measures

*Hospital-Based Inpatient Psychiatric Services

Sponsors for HBIPS measures include: •Centers for Medicaid and Medicare (CMS) •The Joint Commission (TJC), •National Association of Psychiatric Health Systems (NAPHS), •National Association of State Mental Health Program Directors (NASMHPD) •National Research Institute, Inc. (NRI)

HBIPS-6: Post Discharge Continuing Care Plan CreatedHBIPS-7: Post Discharge Continuing Care Plan Transmitted to Next Level of Care Provider Upon Discharge

Cross walk

Hosp.Reason

DC meds

Self Care activities

Crisis ManagementPlan

Coordinate F/up Visits

Easy to understand Plan (AVS)**

Hosp.Reason XPrimary dx

DC meds XCare Plan (ROP*) X XCare Plan transmitted X

HBI

PSH

ospi

tal B

ased

Inpa

tient

Psy

chia

tric

Ser

vice

s

Rare

* Recommendations for next Outpatient Provider (Excellian)

HBI

PS 6

HBI

PS 7

** AVS After Visit Summary for patients (Excellian)

Why is transition planning important?

• Without it – we fail to provide best services to our patients

• Seen by the public and value-based purchasers• Consistent with healthcare system mission to

improve care quality after hospitalization• On going educational, leadership and

performance improvement needed to support Transition Planning on inpatient units