1. Context and Overview of Recommended Actions to Reduce Psychiatric Readmissions Michael Trangle, MD Associate Medical Director, Behavioral Health Division HealthPartners Medical Group/Regions Hospital

2. 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.

3. 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

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

5. Factors that Contribute to Care Transition Challenges - continued 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

6. BMC Psychiatry 2011 – Population Based Study in Australia 140,000 mental health vs. 294,000 non mental health in Western Australia 1990-2006. Focused on preventable re- admissions (10% of all admissions for mental health 49,787) Overall avoidable re-admissions 2-times for mental health vs. non mental health populations Re-admission diagnosis: – Diabetes & Complications – ADE’s (Adverse Drug Events) – COPD / Asthma – Convulsions & Epilepsy – CHF

7. More on Population Based Study with Australia Mental health disease factors which increased re-admissions: – Etoh / Drugs – Affective Psychosis – Schizophrenia Half of all acute preventable hospitalizations could be avoided if mental health re-admission rates = non mental health Disparity of re-admission rates increased over time – Excludes dementia as Mental Health diagnosis, excludes payment / coverage which are not issues in Australia

8. MN RARE BH Data MHA has claims data for all admissions and re- admissions in MN for the past 20 years. Data generally only tracks re-admissions to same hospital. Stratis has Medicare data that includes re- admissions to all hospitals. This data shows that 22%-25% of re-admissions occur at other hospitals.

9. Baseline Data Top 4 DRGs account for 22,000/28,000 Psychiatric admissions per year (79% of admissions) 90% of hospitals with psychiatric units began working on RARE in 2010 – even if psychiatric leaders/staff were only variably involved

10. State-wide Generalized – All Mental Health YearExpectedActual 2008 – 2009-7.8 = baseline readmission rate 20107.8%7.9% 20117.9%7.3% 20127.9%7.2% For 2012, the actual divided by the expected =.91. (9% fewer readmissions than expected). Given the RARE campaign goal to reduce readmissions by 20%, the actual/expected ratio goal is.8. If we start with the figures from 2010, the goal would be to get down to 6.24% overall for the psychiatric readmission rate.

11. DRG Major depressive disorders and other/unspecified – 751 (#1 Psychiatric DRG) Expected Re-admission (2008-2009 baseline)7.5% Actual Re-admissionYear 20107.6% 20116.8% 20127.2% Bipolar disorders – 752 (#2 Psychiatric DRG) Expected Re-admission (2008-2009 baseline)9.0% Actual Re-admission20109.1% 20118.2% 20128.0%

12. DRG Schizophrenia – 753 (#3 Psychiatric DRG) Expected Re-admission (2008-2009 baseline)11.1% Actual Re-admissionYear 201012.6% 201111.2% 20129.9% Depression except major depressive disorder – 754 (#4 Psychiatric DRG) Expected Re-admission (2008-2009 baseline)5.6% Actual Re-admission20105.9% 20115.5% 20125.5%

13. The Five Key Areas The issues that influence avoidable readmissions are many and complex. The five areas below have been identified as a focus for quality improvement efforts. 1.Patient and Family Engagement 2.Medication Management 3.Comprehensive Transition Planning 4.Care Transition Support 5.Transition Communication