RARE Networking Webinar:

“Improving Care Transitions for Patients with Mental Illnesses and Substance Use Disorders”

Speakers: Paul Goering, MD Allina Health, Michael Trangle, MD HealthPartners Medical Group

and Kathy Cummings, RN, ICSI

Objectives

At the end of this session, you will be able to:

• Identify factors that contribute to care transition challenges for people with mental illnesses and substance use disorders (excluding dementia)

• Identify specific interventions in the five key areas that can help reduce avoidable hospital readmissions

Case Studies

Specific population distinctions:• Patient with mental health diagnosis hospitalized for

mental health treatment

• Medical/surgical patient who experiences mental health issue with acute medical issue i.e. AMI patient with depressive components

• Patient with chronic mental health illness hospitalized for care of acute medical problem i.e. schizophrenic patient hospitalized for pneumonia

Why a specific focus on this population?

What do we know about this population from the Minnesota data?

DRG’s ranking by volume of potentially preventable readmissions in 2010

• 4th Major depressive disorders & other/unspecified psychosis

• 9th Bipolar disorders

• 11th Schizophrenia

Mental Illness and Chronic Disease in the Literature

1. Comorbid depressive symptoms in patients with COPD are associated with poorer survival, longer hospitalizations and poorer social functioning.

1. Depressive symptoms predict early rehospitalization for heart failure exacerbations.

1. In patients with Heart Failure, depression is independently associated with poor outcomes.

Mental Illness and Acute Medication Conditions in the Literature

• Post AMI patients have 3 times higher rate of depression and depressed patients have up to 4 times higher mortality rate

• Post CABG patients with depression have up to two times higher mortality rate

• Remember higher incidence of depression in pregnant (14-23%) and post partum patients (10-15%) and arrange for routine screening

Factors that Contribute to Care Transition Challenges

• Diagnosis Specific Factors:– Depression– Mania– Substance Use Disorders– Schizophrenia– Anxiety

Factors that Contribute to Care Transition Challenges

• General Factors: – Stigma associated with diagnosis– Socio-economic challenges– Complex medication regimes– Barriers to family/support person involvement– Access issues to follow-up care– Transportation challenges– Lack of coordination with primary care providers

Five Focus Areas

Patient and Family Engagement

Transition Communication

Transition Support

ComprehensiveDischarge Plan

Medication Management

Recommended Actions for Improved Care Transitions:

Mental Illness and/or Substance Use Disorder

Comprehensive Discharge PlanningA written patient centered plan

must include:

1. Reason for hospitalization including information on disease in terms patient can understand

1. Medications to be take post transition

1. Self-care activities:• Coping skills• Nutrition/Exercise• Recovery goal/plan

4. Crisis Management

Comprehensive Discharge Planning

5. Coordinate and plan for follow-up appointments

6. Transition plan must be written and easy to understand

7. Address physical health considerations

1. Medication reconciliation at each patient transition

1. Patient medication list should contain purpose for each medication and date of completed reconciliation

1. Assure medication availability and affordability

1. Communicate regarding intended plans for medications so clear to all providers, patient and family

1. Assure patient agreement and understanding

Medication Management

6 Screen for other Co-occurring disorders.

7. Special considerations should be given for patients who are: incompetent, confused, on involuntary commitment, having psychotic episodes, newly diagnosed, living alone without support and/or those with cognitive deficits.

Additional strategies: • Consider Medication Therapy

Management (MTM) for patients with special challenges.

• A pharmacist should review orders at the time of discharge

Medication Management

1. Ask the patient to identify family and friends who are their support

1. If patient does not identify a support system, include a surrogate such as case manager or Assertive Community Treatment Team member (ACT team)

1. Involve patient’s identified support system throughout care including development of discharge plan

Patient Family Engagement and Activation

Family is defined by the patient and may be friends rather than relatives.

4. Use the Teach Back method when giving instructions

5. Be knowledgeable of and make frequent referrals to community support services

6. Use Health Literacy Standards such as AHRQ Health Literacy Universal Precautions

Patient Family Engagement and Activation

Care Transition Support

1. Follow-up appointment within 7 calendar days with a provider of mental health services post-hospitalization; receiving provider should have system to accommodate availability

1. For new referrals, facilitate the connections between the patient and the agency

1. All patients with mental illness and chronic or acute physical problems should be seen by their medical provider and follow-up appointment should be made prior to discharge

Care Transition Support

4. An adult mental health patient who does not have a designated primary care provider should be connected to one for prevention interventions and physical assessment and an appointment within 60 days

5. Within 72 hours of transition, a contact with the patient should be made by a team member with knowledge of patient’s history and plan of care

5. Teach Back and open-ended questions should be used to assure understanding of the plan of care, including content and preparation for the follow-up visit

Follow-up visit should focus on:• Patient’s goals for the visit, factors

contributing to admission or ER visit, meds and schedule

• Medication adjustment, follow-up tests, psychosocial environmental factors

• Warning signs

• Review of crisis plan

• Management of medical problems

• OTC medications, legal or illegal substance use or abuse

• Healthy lifestyle choices and supports

Care Transition Support

Other strategies:

• Care Transitions Intervention

• Case or care managers regular follow-up

• Assertive Community Treatment Intervention (ACT)

• Critical Time Interventions (CTI)

Transition Communication1. Mental health provider

notified when patient admitted; primary care notified during hospitalization and prior discharge

1. Ascertain if patient has case manager; if so, notify and involve in care

1. Patients and family should know who is responsible for care and how to contact them

Transition Communication

4. Transition communication responsibilities by physician should follow hospital policy

4. Concise transfer forms with key elements must be sent with the patient in every transfer

4. Direct reports between nursing staff

4. Complete discharge summaries should be received by the accepting facilities within 5 business days or prior to follow-up appointment

Transition CommunicationOther strategies:• Develop a universal patient care

plan template

• Utilize a Patient Health Record

• Allow access to hospital electronic health records for those facilities commonly receiving patients

• Develop resource materials to assist patients and families with care transitions

Owatonna Hospital Emergency Department

System Care Coordination Program

CASE STUDY