Transition of Care
Communication
from the perspective of the outpatient clinic
Nystrom & Associates, Ltd.

Minnesota Based Mental Health Clinic with eight Minnesota locations and two
Washington state locations.

Over 40,000 unique patient visits per year.

Patient population breakdown:


50% State / Federal Funded (Medicaid / Medicare)

Large commercial payer mix (Blue Cross Blue Shield, Medica, Preferred One, Etc)

Small cash pay population
Collaborative partnerships with many MN, WA, and National Organizations:

Nexus (Mille Lacs Academy, Gerard Academy)

Prairie Care

Health Partners

Medica

Multicare Associates (Fridley, Roseville, and Blaine Medical Centers)
RARE – The Five Key Areas
 Patient
/ Family Engagement and Activation
 Medication
Management
 Comprehensive
 Care
Transition Planning
Transition Support
 Transition
Communications
Patient / Family Engagement
and Activation

Systemic communication is important from the
start!

The value of the referring entity in getting
Releases of Information.

Family System involvement expectations from
point of referral on.
 This
is an active discussion and dialogue!
Medication Management
 The
importance of accuracy.
 Dossing
expectations and communication.
 Existing
 Cross
medications
Clinic / Provider illness management.
 Additional
resources – Family, Friends, Case
Workers, Group Homes, Etc.
Comprehensive Transition
Planning

Clear plan of services

What follow up, when, where, goals?

Communication of documentation and information
from referent

Set up release of information and communication
expectations with patient at this time.
Care Transition Support

Timelines for care – clear expectations on urgency
(NCQA, Joint Commission, Patient Need)

Care needs, medication management, community
services, psychotherapy, chemical dependency,
etc.

The key to a good referral
 Patient
buy in, informed consent, clear communication
and expectations
Transition Communication - The
Culmination of the 5 Key Areas

Back and forth communication expectations.
 Needs
of referent, needs of the clinic, needs of the
patient

Release of information on both sides.
 Independent
control – what are we able to
take ownership of vs. what do we need to
depend on other for.
 Clear
start.
expectations on all areas from the
Collaborative Partnerships and
Care Coordination
 Value
of formalizing collaborative
partnerships
 Use
of a small handful of providers or one
provider vs. many
 Communication
expectations – what to
bring to the table
Time makes all things fuzzy

Over time memory fades.

Importance of writing it down.

Referral guidelines

Memorandum of Understanding

Contracts

Periodic review and check in

If it doesn’t work, FIX IT!

Clear expectations from day 1

Who is involved?

How do they communicate?

When it breaks, who is going to fix it?

Did you write it down?
When good intentions fail

The “set it and forget it” mentality

Assumptions hurt patients care

Failure is an opportunity – Do not overlook it!