Incorporation of behavioral health services into Transitional Care

Incorporation of behavioral health services into Transitional Care Management; a model for interprofessional team-based posthospital care in the academic family medicine clinic. Andrew Slattengren, DO Michele Mandrich, MSW Erika Campbell-Ford, LPN Jerica Berge, Ph. D, MPH, LMFT University of Minnesota Medical School, North Memorial Family Medicine Residency, Broadway Family Medicine Clinic

Disclosures • None

Objectives On completion of this session, the participants should be able to: • Describe what reimbursement changes under the Affordable Care Act are stimulating new provider focus on improving transitions of care. • Discuss the rationale for incorporating behavior health services into post-hospital Transitional Care Management visits. • Explain how you could integrate behavioral health services into current clinical processes at your site to enhance patient care.

Why worry about transitions? • Poorly coordinated care transitions from the hospital to other care settings cost $12 billion to $44 billion per year (1) • Poor transitions have been associated with a number of adverse health outcomes (2)

Reimbursement Changes • In October 2012, the Centers for Medicare and Medicaid Services (CMS) instituted penalties for facilities with high readmission rates within 30 days of discharge for some conditions • CMS encouraged outpatient providers to focus on safe transitions through new reimbursement codes issued in 2013 – With these codes, providers may bill for care transitions services if they see patients within 14 days of discharge from a hospital, skilled nursing facility, or rehabilitation facility

Our Response • Initiated a Transitional Care Management (TCM) process in 2014 • Shared-visit with Pharm. D and the medical provider present

Evidence-based guidance • There is limited data on the use of behavioral health services • One of the most effective interventions (3): – incorporation of comprehensive discharge planning – patient-directed goal setting – individualized care planning – educational and behavioral strategies – clinical management

AMA Expert Panel Consensus (4) • 5 tasks required for safe transitions: – patient assessment – patient goal setting to inform the care plan – coaching in self-management – medication management – care coordination

Why this doesn’t happen • Very few medical providers have the time or expertise to complete all five of these recommendations in the course of a scheduled patient visit

Further Enhancement • In June 2015, we started incorporating behavioral health (BH) services into our established TCM process

Role of BH during TCM visit • Collaboratively conduct the visit • Assess patient mental health symptoms and provide a mental health diagnosis (if appropriate) • Help draw out the patient’s “story” to conjointly formulate a treatment plan • Use Motivational Interviewing to address lifestyle behaviors and goal setting • Make recommendations for mental health services • Provide point-of-care interventions as needed

TCM Standard Work • Nursing staff schedules visit with patient within 1 week of discharge • Patient informed that it will be a team visit with multiple providers to give them best care

TCM Standard Work • All providers perform pre-visit planning • Huddle between team providers the day of the visit –Create agenda

TCM Standard Work, • Integrated team visit with: – MD/DO provider – Behavioral health – Pharmacy • Notes written in chart by each provider • Adjust the visit structure as needed

Common Diagnoses Seen • • • Diabetes Cardiovascular Disease/Myocardial Infarction Asthma Anxiety—Panic Attacks Depression, Suicide Attempt Self-limited acute illness

9 months of TCM with BH Total hospital discharges 353 • TCM visits 191 • TCM visits with BH 84 (44%)

9 months of TCM with BH Readmission Rates • TCM 16/191 = 8. 4% • TCM with BH 6/84 = 7. 1%

9 months of TCM with BH Provider Satisfaction (9 mo vs baseline) • During my usual clinic shifts, I am able to have Behavioral Health see a patient during the visit if needed. • 67% agree (baseline 54%) • 29% neither agree nor disagree (33%) • 5% disagree (13%)

9 months of TCM with BH Provider Satisfaction (9 mo vs baseline) • Having Behavioral Health see a patient during a TCM (Hospital Follow-up) visit improves patient care. • 85% agree (baseline 70%) • 10% neither agree nor disagree (30%) • 5% disagree (0%)

9 months of TCM with BH Provider Satisfaction (9 mo vs baseline) • I find the recommendations from Behavioral Health helpful in caring for my patients. • 90% agree (baseline 83%) • 10% neither agree nor disagree (17%) • None disagree

TCM with BH Patient Satisfaction • I feel that having providers other than my doctor see me today was helpful. – 24 responses – 1 N/A – 20 agree – 3 somewhat agree – 0 disagree

Lessons Learned • Patients will decline to see BH and feel that they are being labeled as “mentally unstable” – Reassure the patient that the role of BH does not need to involve labeling

Lessons Learned • Scheduling and billing systems are rigid when team-based care requires flexibility and creativity – Scheduling conflicts between desired medical provider and BH availability – No-show for visit – may show up later in day • This is a step toward total cost of care and a step back from fee for service – Much of what BH does in these visits is not billable

Lessons Learned • Patients request additional BH services • Patients express better understanding of health conditions and lifestyle management • Having a BH coordinator who is engaged is key

References 1) L. O. Hansern, R. S. Young, K. Hinami, et al. 2011. Interventions to Reduce 30 -Day Rehospitalization: A Systematic Review. Annals of Internal Medicine 155: 520 -8. 2) C. S. Kim, S. A. Flanders. 2013. Transitions of Care. Annals of Internal Medicine 58(5 Part 1): ITC 3 -1. 3) M. D. Naylor, L. H. Aiken, E. T. Kurtzman, et al. 2011. The Importance of Transitional Care in Achieving Health Reform. Health Affairs 30(4): 746 -54. 4) P. E. Sokol, M. K. Wynia. “There and home again, safely: Five responsibilities of ambulatory practices in high quality care transitions. ” AMA Expert Panel on Care Transitions, Chicago (2013).

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