Comprehensive Transition Planning
During the Hospital Stay
Dr. Paul Goering
VP Mental Health Clinical Service Line
Allina Health
RARE Mental Health Collaborative Learning Day
February 19, 2014
What is Comprehensive
Transition Planning?
Collaboration between patient, their family, and mental
health providers to:
• Ensure patient’s needs are considered
• Information is useful to patients and their
subsequent providers
• Did we provide what is needed for success?
Different from discharge summary
• Patient focus
• Includes patient-specific recommendations
* From Recommended Actions for Improved Care Transitions Mental Illnesses and/or
Substance Use Disorders ( RARE Campaign)
Comprehensive Transition Planning
Key Recommendations for All Patients
Reason for Hospitalization and Transition Plan
Patient/Family Focused
Communicated at an appropriate level of health literacy
Medication management
Comprehensive Medication Reconciliation process
Dose, times, how to take, what to avoid
Where to obtain refills,
Indication for medication
This has been a technical challenge!
* From Recommended Actions for Improved Care Transitions Mental Illnesses and/or
Substance Use Disorders ( RARE Campaign)
Key Recommendations for All Patients
(Continued )
Self Care
-
Nutrition
Exercise
Crisis Management Plan
Coordination and follow-up appointments
- Engage patient to identify and arrange appointments
early during patient’s hospital stay
- Coordinate visit with patient and their caregivers at
home to insure appointment can be kept
Transition plan written for patient
Written at patient’s level of health literacy
* From Recommended Actions for Improved Care Transitions Mental Illnesses and/or
Substance Use Disorders ( RARE Campaign)
Comprehensive Transition Planning
Specifically for Patients with Mental Health Problems
•
•
•
•
Coping Skills
Nutrition/Exercise, diet
Recovery goals and plan
If acute of chronic medical condition with new depression
or anxiety diagnosis, then schedule a mental health
follow-up visit
• If there are physical health considerations and patient
does not have a primary care providers, then engage
patient and help arrange a follow-up visits
5
Are we providing what patients
need for success?
Collaboration and Recommendations
for Next Provider
6
Comprehensive Transition Planning:
Collaborating with the Next Provider
• Barriers that may limit patients’ options
post-hospital mental health care
- Limited access to specialty providers
- Geographic
- Payment & insurance
Comprehensive Transition Planning:
Collaborating with the Next Provider
• Anticipating patients discharge needs
- Engage patient choice early
- Multidisciplinary Transition Conference to
communicate among patient and Care Team
- Communicate the Plan and
Recommendations immediately after
discharge
- Timely follow-up appointments for priority
needs
Strategies that Improve Patient and Next
Provider Transition Planning
• Establish best practice and garner leadership
support
• Changing the culture
- Collaborate as team
- Look beyond the current inpatient stay
- Use patient survey results
• Performance Improvement Process
- Establish measurable goals
- Standardize Discharge Plan and Recommendations
- Provide feedback on success
Strategies that Improve Patient and Next
Provider Transition Planning
• Leverage Electronic Health Care Records where
available (EHR)
• Allina uses Excellian (EPIC)
- Pilot for standardize discharge summary for Mental
Health inpatients and recommendations to next
provider
- Automatic reminders and prompts for HBIPS
- Automatic Routing to Next provider
- Creates an After Visit Summary for the patient
These RARE Complement
HBIPS* Quality Improvement Measures
*Hospital-Based Inpatient Psychiatric Services
HBIPS-6: Post Discharge Continuing Care Plan
Created
HBIPS-7: Post Discharge Continuing Care Plan
Transmitted to Next Level of Care Provider
Upon Discharge
Rare Initiatives dovetail with
HBIPS National Quality
Improvement Measures
Sponsors for HBIPS measures include:
• Centers for Medicaid and Medicare (CMS)
• The Joint Commission (TJC),
• National Association of Psychiatric Health Systems (NAPHS),
• National Association of State Mental Health Program Directors (NASMHPD)
• National Research Institute, Inc. (NRI)
Rare
HBIPS 7
HBIPS 6
Hosp.
Reason
HBIPS
Hospital Based Inpatient Psychiatric Services
Cross walk
Hosp.
Reason
DC
Self Care
meds activities
Crisis
Coordinate Easy to
Management F/up Visits understand
Plan
Plan (AVS)**
X
Primary dx
DC meds
X
Care Plan
(ROP*)
X
Care Plan
transmitted
X
* Recommendations for next
Outpatient Provider (Excellian)
X
** AVS After Visit Summary for
patients (Excellian)
Why is transition planning
important?
• Without it – we fail to provide best services to our
patients
• Seen by the public and value-based purchasers
• Consistent with healthcare system mission to
improve care quality after hospitalization
• On going educational, leadership and
performance improvement needed to support
Transition Planning on inpatient units