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
Kathy to open up and get Webinar started

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
Kathy to describe work of RARE Mental Health work group throughout the last year and collaboration around the Webinar and Recommended Actions Document

3. As we know, there are many issues that have lead up to the present state of readmissions. These issues need to be taken into consideration when mapping the course for improvement.
Fragmentation of health care
Lack of available patient information
Patient/Family goals not understood
Medications not reconciled on admission or transitions
Discharge planning not started, inconsistent
Lack of communication between care givers
Polypharmacy and complex medications
Outstanding labs, tests not communicated
No follow-up plan or plan is not communicated
Incomplete information of what was done during hospitalization
Incomplete handover information
Accountability for care is not defined
End of Life discussions not held

4. Case Studies
Michael to share case study- suicidal patient who had surgery and overdosed on the prescribed pain meds.
Paul to share case study- patient with mental illness in inpatient psych setting being discharged to a different system, with payer issues and communication issues.

5. Why a specific focus on this population?
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
Kathy to identify distinctions in populations

6. 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
Kathy to share from PPR data

7. Mental Illness and Chronic Disease in the Literature
Comorbid depressive symptoms in patients with COPD are associated with poorer survival, longer hospitalizations and poorer social functioning.
Depressive symptoms predict early rehospitalization for heart failure exacerbations.
In patients with Heart Failure, depression is independently associated with poor outcomes.
Kathy to identify key findings from the literature about impact of mental illness on readmissions for acute conditions and nature of the challenge with psych patients.

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
Michael to describe and elaborate

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
Paul to describe and elaborate

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

12. Recommended Actions for Improved Care Transitions: Mental Illness and/or Substance Use Disorder
Introduce document created by work group

13. Comprehensive Discharge Planning
A written patient centered plan must include:
Reason for hospitalization including information on disease in terms patient can understand
Medications to be take post transition
Self-care activities:
Coping skills
Nutrition/Exercise
Recovery goal/plan
Crisis Management
Paul

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
Paul

15. Medication Management
Medication reconciliation at each patient transition
Patient medication list should contain purpose for each medication and date of completed reconciliation
Assure medication availability and affordability
Communicate regarding intended plans for medications so clear to all providers, patient and family
Assure patient agreement and understanding
Paul

16. Medication Management
Screen for other Co-occurring disorders.
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
Paul

17. Patient Family Engagement and Activation
Ask the patient to identify family and friends who are their support
If patient does not identify a support system, include a surrogate such as case manager or Assertive Community Treatment Team member (ACT team)
Involve patient’s identified support system throughout care including development of discharge plan
Family is defined by the patient and may
be friends rather than relatives.
Michael

18. Patient Family Engagement and Activation
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
Michael

19. Care Transition Support
Follow-up appointment within 7 calendar days with a provider of mental health services post-hospitalization; receiving provider should have system to accommodate availability
For new referrals, facilitate the connections between the patient and the agency
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
Michael

20. Care Transition Support
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
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
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
Michael

21. 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
Michael

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)
Michael

23. Transition Communication
Mental health provider notified when patient admitted; primary care notified during hospitalization and prior discharge
Ascertain if patient has case manager; if so, notify and involve in care
Patients and family should know who is responsible for care and how to contact them
Michael

24. Transition Communication
Transition communication responsibilities by physician should follow hospital policy
Concise transfer forms with key elements must be sent with the patient in every transfer
Direct reports between nursing staff
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
Michael

26. CASE STUDY
Owatonna Hospital Emergency Department System Care Coordination Program
Elizabeth Keck to share Owatonna Hospital-Emergency Department program