Context and Overview of
Recommended Actions to Reduce
Psychiatric Readmissions
Michael Trangle, MD
Associate Medical Director, Behavioral Health Division
HealthPartners Medical Group/Regions Hospital
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.
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 (1015%) and arrange for routine screening
Factors that Contribute to Care Transition
Challenges
• Diagnosis Specific Factors:
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Depression
Mania
Substance Use Disorders
Schizophrenia
Anxiety
Factors that Contribute to Care Transition
Challenges - continued
• General Factors:
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–
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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
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 readmissions (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
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
MN RARE BH Data
• MHA has claims data for all admissions and readmissions in MN for the past 20 years.
• Data generally only tracks re-admissions to
same hospital.
• Stratis has Medicare data that includes readmissions to all hospitals. This data shows
that 22%-25% of re-admissions occur at other
hospitals.
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
State-wide Generalized – All Mental Health
Year
Expected
Actual
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7.8 = baseline
readmission rate
2010
7.8%
7.9%
2011
7.9%
7.3%
2012
7.9%
7.2%
2008 – 2009
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.
DRG
Major depressive disorders and
other/unspecified – 751
(#1 Psychiatric DRG)
Expected Re-admission
(2008-2009 baseline)
Actual Re-admission
Bipolar disorders – 752
(#2 Psychiatric DRG)
7.5%
Year
2010
7.6%
2011
6.8%
2012
7.2%
Expected Re-admission
(2008-2009 baseline)
Actual Re-admission
9.0%
2010
9.1%
2011
8.2%
2012
8.0%
DRG
Schizophrenia – 753
(#3 Psychiatric DRG)
Expected Re-admission
(2008-2009 baseline)
Actual Re-admission
Depression except major depressive
disorder – 754
(#4 Psychiatric DRG)
11.1%
Year
2010
12.6%
2011
11.2%
2012
9.9%
Expected Re-admission
(2008-2009 baseline)
Actual Re-admission
5.6%
2010
5.9%
2011
5.5%
2012
5.5%
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