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

Harold Alan Pincus, MD; Professor and Vice Chair, Dept. of Psychiatry, Columbia University

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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

London NHS 5

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““Crossing the Quality ChasmCrossing the Quality Chasm””

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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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1010ICSI RARE Webinar

04.21.2014

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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““Crossing the Quality ChasmCrossing the Quality Chasm””

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34Cornell Faculty Council Grand Rounds

3/5/14 34

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, kcummings@icsi.org

Jill Kemper, jkemper@icsi.org