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RARE Networking Webinar:Improving Care Transitions for Patients with Mental Illnesses and Substance Use Disorders Speakers: Paul Goering, MD Allina Health,

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Presentation on theme: "RARE Networking Webinar:Improving Care Transitions for Patients with Mental Illnesses and Substance Use Disorders Speakers: Paul Goering, MD Allina Health,"— Presentation transcript:

1 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

2 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


4 Case Studies

5 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?

6 What do we know about this population from the Minnesota data? DRGs ranking by volume of potentially preventable readmissions in th Major depressive disorders & other/ unspecified psychosis 9 th Bipolar disorders 11 th Schizophrenia

7 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.

8 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

9 Factors that Contribute to Care Transition Challenges Diagnosis Specific Factors: –Depression –Mania –Substance Use Disorders –Schizophrenia –Anxiety

10 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

11 Five Focus Areas Patient and Family Engagement Transition Communication Transition Support Comprehensive Discharge Plan Medication Management

12 Recommended Actions for Improved Care Transitions: Mental Illness and/or Substance Use Disorder

13 Comprehensive Discharge Planning A 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

14 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

15 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

16 6Screen 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

17 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 patients 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.

18 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

19 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

20 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 patients 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

21 Follow-up visit should focus on: Patients 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

22 Care Transition Support Other strategies: Care Transitions Intervention Case or care managers regular follow-up Assertive Community Treatment Intervention (ACT) Critical Time Interventions (CTI)

23 Transition Communication 1.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

24 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

25 Transition Communication Other 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

26 Owatonna Hospital Emergency Department System Care Coordination Program CASE STUDY

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