RARE ASSESSMENT
Mental Illness and/or Substance Use Disorders
Patient and Family Engagement
1.
2.
3.
4.
5.
6.
7.
Always Sometimes Rarely
Never
Always Sometimes Rarely
Never
Do you ask the patient to identify family and friends who
comprise their support network?
Are the patient’s caregivers involved in discussions and
decisions about care?
Is Teach Back used when educating the patient and their
caregivers?
Are teaching materials written in easily understood language?
Have appropriate releases of information been obtained
include family and care givers?
Are care teams aware of community support services
available?
to
If the patient does not have a family support system, has a
surrogate been included/assigned?
Medication Management
1. Are the medications reconciled at each patient transition to
ensure safe, accurate and appropriate medication therapy?
2. Does the medication list contain the optimal elements?
Optimal elements in the medication list include:
 Name of the medication
 Purpose of the medication
 Side effects
 How to take the medication
 When to take the medication
 Future anticipated dosage changes, e.g. titrating doses
 Current changes in the medication regime
 Formulary availability, cost and generic alternatives
 Possible interactions with other medications and
substances such as alcohol and food
3. At every patient encounter, are the medications the patient is
taking verified with the patient?
4. At every patient encounter, is the patient asked how he/she is
taking their medications?
Medication Management
Always Sometimes Rarely
Never
Always Sometimes Rarely
Never
5. Is Teach Back consistently used when teaching the patient
about medications?
6. If the patient is on a complex medication regime is Medication
Therapy Management (MTM) offered?
7. Has consideration for specific patient condition and issues (i.e.
suicidal issues) been given when ordering potentially lethal
medications?
8. Is the medication plan clearly communicated to all providers
caring for the patient, the patient, and the patient’s family?
9. Are patients with co-occurring psychiatric and medical
disorders screened for possible substance use disorder?
10. For patients who are considered to be in a special population
(e.g. confused, incapacitated with respect to medical decisionmaking, in the midst of acute psychotic episodes, etc.) and it is
recognized that specific additional strategies may enhance
medication adherence, has have the following strategies been
implemented?
 Direct observation of medication use
 Administration of depot medications
 Involvement of a case/care manage
Comprehensive Transition Planning
1. Does the patient receive a written patient-centered transition
plan must include the following:
a.
Reason for hospitalization, including information
on diagnosis in terms the patient and family can
understand.
b. Medications to be taken post-transition, including,
as appropriate, resumption of preadmission
medications
c. Self-care activities such as exercise and diet
d. Coping skills (sleep hygiene, self-soothing)
e. Nutrition and diet
f. Recovery goal/plan
g. Crisis management: condition-specific symptom
recognition and management
h. Coordination and planning for follow-up
appointments
- For patients with acute or chronic medical conditions and
newly diagnosed depression or anxiety, a follow-up
appointment with a mental health provider in addition to
their primary care provider
- Involves coordination with the patient and family to ensure
they will be able to get to and keep the appointment.
2. Does the patient have a crisis management plan upon
discharge?
Transition Care Support
1. Does the patient have a follow up appointment with a provider
of mental health services within seven calendar days posthospitalization or sooner if their condition warrants, to review
progress and plan of care?
2. For new referrals, do you facilitate the connection between
the patient and the agency to which the patient is being
referred to ensure a successful connection?
3. Does the receiving mental health provider have a system to
accommodate availability for transitioned patients within
seven calendar days?
4. If there are physical health considerations and the patient
does not have a primary care physician or clinic, do you help
the patient obtain one?
5. Do you facilitate connection with a primary care provider and
an appointment within 60 days for physical assessment and
prevention intervention?
6. Within 72 hours of transition, does a team member with
knowledge of the patient’s history and plan of care contact the
patient?
7. Does your organization utilize:
 Care Transitions Intervention,
 Case or Care Managers
 Assertive Community Treatment Intervention, or
 Critical Time Intervention?
8.
Does the follow-up contact or visit include:
a. Patients goals for the visit
b. Medications the patient is taking and on what schedule
c. Patient’s needs for medication adjustment
d. Follow-up on test results, monitoring and testing
e. Advance directives, specific future treatments such as
Physician Orders for Life Sustaining Treatment (POLST)
f.
Patient needs for instruction on self-management using
Teach Back
g. Explanation of warning signs and how to respond using
Teach Back
h. Instructions for seeking emergency and non-emergency
after-hours care
Asking about the patient’s living situation, access to
transportation
j. Expect questions about why and how the patient’s medial
problems are being managed; Expect questions
regarding OTC medications and healthy lifestyle choices.
i.
Always Sometimes Rarely
Never
Always Sometimes Rarely
Transition Communication
1. Do you send the discharge summary within 3 business days
from the patients’ discharge?
2. Do you notify the patient’s primary care and mental health
providers when a patient is admitted or discharged?
3. Does the patient have a county case manager, clinic care
manager or health plan case manager? If so, do you notify
them of the hospitalization and involve the care manager in the
development of the care plan.
4. Do you use a universal patient care plan template among all
outpatient providers?
5. At every point during care transitions, does the patient, their
family and any caregivers know who is responsible for care
and how to contact them. Do Care providers also know who
is responsible at each transition?
6. Are complete transition summaries received by the accepting
facility within five business days or within adequate time to be
available for the initial follow-up appointment?
Never