Care Transitions Interventions in Mental Health
Harold Pincus, MDProfessor and Vice Chair, Department of
Psychiatry, Columbia University
April 21, 2014
Dial 866-639-0744, no passcode needed
Problem StatementFor adults with behavioral health conditions
(mental illness/substance abuse), transitions from points of care pose substantial obstacles to successful treatment outcomes
Inpatient to outpatient transitions are particularly problematic from an individual, health system and societal perspective
Significant risks include hospital readmissions, care disengagement and symptom exacerbation
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Crossing the Quality ChasmCrossing the Quality Chasm
““Quality problems occur typically Quality problems occur typically not because of failure of goodwill, not because of failure of goodwill, knowledge, effort or resources knowledge, effort or resources devoted to health care, but because devoted to health care, but because of fundamental shortcomings in the of fundamental shortcomings in the ways care is organizedways care is organized””
Only 50% chance of getting Only 50% chance of getting appropriate careappropriate care
The American health care delivery The American health care delivery system is in need of fundamental system is in need of fundamental change. The current care systems change. The current care systems cannot do the job. cannot do the job. Trying harderTrying harder will not work: will not work:Changing systems of care will!Changing systems of care will!
4Columbia-Bassett Presentation 02.05.2014
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The State of Health Care Quality 2006The State of Health Care Quality 2006, NCQA, NCQA
There are, however, disturbing There are, however, disturbing exceptions to this pattern of [overall exceptions to this pattern of [overall health care quality] improvement. The health care quality] improvement. The quality of care for Americans with mental quality of care for Americans with mental health problems remains as poor today health problems remains as poor today as it was several years ago. as it was several years ago.
www.ncqa.orgwww.ncqa.org
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Follow-up After Hospitalization:Follow-up After Hospitalization for Mental Illness: 7 DaysTrends, 1998-2005
100%
80%
60%
40%
20%
0%‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05
Commercial
Medicaid
Medicare
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Follow-Up After Hospitalization:Within 7 Days Post-Discharge- HMO Means Trends, 2002-2009
0
20
40
60
80
100
'02 '03 '04 '05 '06 '07 '08 '09
Commercial
Medicare
Medicaid
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Three Focal QuestionsWhat are the components of existing
frameworks/interventions to improve care transitions? To what extent have they been evaluated?
Have care transitions interventions been developed/adapted/evaluated specific to the behavioral health population?
How can current intervention frameworks be modified to address transitions specifically focused on behavioral health populations who are hospitalized to enhance continuity of care, reduce readmissions and improve outcomes?
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Background: TransitionsMajor types of transitions among
persons with behavioral health conditions:Inpatient to outpatient (mental
health/substance abuse)Between home and hospital/EDBetween nursing home or post-acute care
services and hospital/EDCriminal justice system and outpatient or
inpatient care12
Background: Efforts to Reduce RehospitalizationsMost extensive efforts are in areas of
care outside of behavioral healthModels that aim to improve care in
transitions have largely focused on:ElderlySpecific illness groups (Diabetes,
Cardiovascular)State/system-specific quality
initiativesState/system-specific policies directed
at reducing readmissions13
Background: PoliciesPolicies and structures to reduce
readmissions include:ACOsMedical Homes/Health HomesPublic reportingOverarching financial models (e.g., capitation)Bundling inpatient and outpatient carePenalties related to readmission ratesValue-based purchasing
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MethodsSystematic literature/web search, snowballing,
etc.Including grey literature, education, T/A,
implementation material Inclusion criteria:
1)Intervention models descriptionsa) General medicineb) Mental health
2)Trials or evaluation studiesa) General medicineb) Mental health
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Major Care Transition Models in General Medical CareCare Transitions Intervention (CTI); Eric ColemanTransitional Care Model (TCM); Mary Naylor
Adapted Models/Initiatives:Reducing Avoidable Readmissions Effectively (RARE) Better Outcomes for Older Adults through Safe
Transitions (BOOST)Transforming Care at the Bedside (TCAB)Re-engineered Discharge (RED) Geriatric Resources for Assessment and Care of Elders
(GRACE)Guided Care ModelBridge; Illinois Transitional Care ConsortiumCenters for Medicaid and Medicare Innovation Center
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Care Transitions Intervention (CTI); Eric ColemanFour components:
1) Patient-centered record2) Pre-discharge checklist/tool of critical activities to
empower patients3) Pre-discharge patient session with a Transition
Coach4) Transition Coach follow-up visits and calls
Intervention based on “Four Pillars”:1) Medication self-management2) Use of a dynamic patient-centered record3) Primary care and specialist follow-up4) Patient knowledge of red flags
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Transitional Care Model (TCM); Mary NaylorSimilar in scope to CTI, but differs in approachFocuses on chronically ill patients who have
been hospitalized for common medical and surgical conditions
Nurse-led, multi-disciplinary intervention that includes:screening; engaging the elder/caregiver;
managing symptoms; educating/promoting self-management; collaborating; assuring continuity; coordinating care; and maintaining relationship
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How CTI and TCM Relate to Other ModelsAll adapted models found included the major
components of the CTI and TCM:Recognize that healthcare delivery and support are
delivered in silos, with a general lack of communication and collaboration
Focus on elderly and/or chronically ill populationUtilize a “health coach”, whether a specially trained
coach or an assigned nurse or social workerInclude pre-discharge planning with the patientFollow-up visits and/or calls with the patient by the
coachPatient/family takes an active and responsible role
in his/her care19
Availability, Responsiveness, and Continuity (ARC)Only model found that focused specifically on
mental and behavioral health; designed to support the improvement of social and mental health services for children
Uses “change agents” to apply 10 intervention components: personal relationships, network development, team building, information and assessment, feedback, participatory decision-making, conflict resolution, continuous improvement, job redesign, and self-regulation
4 phases: problem identification, direction setting, implementation, and stabilization
All within three levels : community, organization, and individual
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“What, For Whom, By Whom, Where, When, and How”What: components that constitute the model
based upon themes from existing intervention models
For Whom: specific clinical populations that are targeted
By Whom: which professionals (and caregivers/consumers) play which roles
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“What, For Whom, By Whom, Where, When, and How”Where: setting is vital to understanding type of
implementations and type of system the patients and providers are part of
When: key time points of intervention (and for collection of metrics)
How: implementation strategies/models, T/A, training, infrastructure development, and measurement/communication/technology capabilities, etc.
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Care Transitions Intervention Components 1) Prospective Modeling2) Patient and Family Engagement3) Transition Planning4) Care Pathways5) Information Transfer/Personal Health Record
(PHR)6) Transition Coaches/Agents7) Provider Engagement8) Quality Metrics and Feedback9) Shared Accountability
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Components: 1 of 9
Prospective ModelingIdentify who is at greatest riskIdeally use community/population-specific data
Transition phase/site: Pre-hospital
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Components: 2 of 9Patient and Family EngagementAuthentic inclusion of patient and family in treatment plan
Transition phase/site: Pre-Hospital, Hospital, Outpatient, Home
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Components: 3 of 9Transition Planning
Collaboratively establish appropriate client-specific plan for transition to next point of care
Transition phase/site: Hospital
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Components: 4 of 9Care Pathways
Specific clinical/procedural guidelines and instructions, i.e., what to do when
Includes assessment, medications, psycho-social interventions/management, self-care instructions, follow-up, etc.
Linkage with national guidelinesCustomize to local community/populationTransition phase/site: Hospital,
Outpatient, Home
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Components: 5 of 9Information Transfer/Personal Health Record (PHR)Ensuring that all information is communicated, understood and managed
Links patient, caregivers, and providers
Transition phase/site: Hospital, Outpatient, Home
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Components: 6 of 9Transition Coaches/Agents
Roles/tasks, competencies, training and supervision should be specified
Training includes planning tools, red flags, client engagement/education strategies
Transition phase/site: Pre-hospital, Hospital, Outpatient, Home
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Components: 7 of 9Provider Engagement
Providers at each level of care should have clear responsibility and plan for implementing all transition procedures/interventions
Communication and handoff arrangements among providers and organizations should be pre-specified in a formal way
At a patient-specific level, providers at each level of care should know what the plan is
Transition phase/site: Pre-hospital, Hospital, Outpatient, Home
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Components: 8 of 9Quality Metrics and Feedback
Gather metrics on follow-up post-hospitalization, rehospitalization, and other feedback on process and outcomes and consumer/family perceptions
Feedback to (and use by) providers for quality improvement and accountability.
Transition phase/site: Pre-hospital, Hospital, Outpatient, Home
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Components: 9 of 9Shared Accountability
All providers share in expectations for quality as well as rewards/penalties
Accountability mechanisms may include financial mechanisms and public reporting with regard to quality and value
Consumers/families share in accountability as well
Transition phase/site: Hospital, Outpatient
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Discussion QuestionsAre there any other care transitions models or initiatives
that you are aware of in behavioral health?
Thinking specifically about intervention components for people hospitalized for behavioral health conditions: Are there components missing? Are some components unnecessary?
With regard to each component: What specific issues need to be considered in adapting to a
SMI context?
To what extent can these elements be extrapolated for people hospitalized for general medical conditions who also have significant behavioral health co-morbidity?
Issues re: For Whom, By Whom, Where, When, How ?
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Care Transitions Intervention Components (draft)1) Prospective Modeling2) Patient and Family Engagement3) Transition Planning4) Care Pathways5) Information Transfer/Personal Health Record
(PHR)6) Transition Coaches/Agents7) Provider Engagement8) Quality Metrics and Feedback9) Shared Accountability
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Upcoming RARE Events….
Stay tuned for the next RARE Mental Health Webinar’s:
May 19, 2014 12:00 p.m. - 1:00 p.m. CSTAllina Health Owatonna - In-REACH ProgramElizabeth Keck, MSW, L.G.S.
June 26, 2014 12:00 – 1:00 p.m. CSTNew York Office of Mental Health - Dr. Molly Finnerty
Future webinars…
To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Networking Webinars, contact:
Kathy Cummings, [email protected]
Jill Kemper, [email protected]