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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
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
Case Studies
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
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
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
(10-15%) and arrange for routine screening
Factors that Contribute to Care
Transition Challenges
• Diagnosis Specific Factors:
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–
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Depression
Mania
Substance Use Disorders
Schizophrenia
Anxiety
Factors that Contribute to Care
Transition Challenges
• General Factors:
–
–
–
–
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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
Five Focus Areas
Patient and
Family Engagement
Transition Communication
Comprehensive
Discharge
Plan
Medication Management
Transition Support
Recommended Actions for
Improved Care Transitions:
Mental Illness and/or
Substance Use Disorder
Comprehensive Discharge Planning
A written patient centered plan
must include:
1.
Reason for hospitalization including
information on disease in terms
patient can understand
1.
Medications to be take post transition
1.
Self-care activities:
•
•
•
4.
Coping skills
Nutrition/Exercise
Recovery goal/plan
Crisis Management
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
Medication Management
1.
Medication reconciliation at each
patient transition
1.
Patient medication list should
contain purpose for each
medication and date of completed
reconciliation
1.
Assure medication availability and
affordability
1.
Communicate regarding intended
plans for medications so clear to all
providers, patient and family
1.
Assure patient agreement and
understanding
Medication Management
6
Screen for other Co-occurring
disorders.
7.
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
Patient Family Engagement and Activation
1. Ask the patient to identify family
and friends who are their support
1. If patient does not identify a
support system, include a
surrogate such as case manager
or Assertive Community
Treatment Team member (ACT
Family is defined by the patient and may
team)
be friends rather than relatives.
1. Involve patient’s identified
support system throughout care
including development of
discharge plan
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
Care Transition Support
1.
Follow-up appointment within 7
calendar days with a provider of
mental health services posthospitalization; receiving provider
should have system to
accommodate availability
1.
For new referrals, facilitate the
connections between the patient
and the agency
1.
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
Care Transition Support
4.
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
5.
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
5.
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
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
Care Transition Support
Other strategies:
• Care Transitions Intervention
• Case or care managers
regular follow-up
• Assertive Community
Treatment Intervention (ACT)
• Critical Time Interventions
(CTI)
Transition Communication
1. Mental health provider
notified when patient
admitted; primary care
notified during hospitalization
and prior discharge
1. Ascertain if patient has case
manager; if so, notify and
involve in care
1. Patients and family should
know who is responsible for
care and how to contact them
Transition Communication
4.
Transition communication
responsibilities by physician should
follow hospital policy
4.
Concise transfer forms with key
elements must be sent with the
patient in every transfer
4.
Direct reports between nursing staff
4.
Complete discharge summaries
should be received by the
accepting facilities within 5
business days or prior to follow-up
appointment
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
CASE STUDY
Owatonna Hospital
Emergency Department
System Care Coordination
Program
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