Bridging Transitions of Care From Hospital to Community on the Foundation of Integrated and Collaborative Care
We build too many walls and not enough bridges.—attributed to Joseph Fort Newton (1)If you are good at building bridges, you will never fall into the abyss!—Mehmet Murat Ildan (2)
On October 27, 1969, Prosenjit Poddar killed Tatiana Tarasoff. Plaintiffs, Tatiana’s parents, allege that two months earlier Poddar confided his intention to kill Tatiana to Dr. Lawrence Moore, a psychologist employed by the Cowell Memorial Hospital at the University of California at Berkeley. They allege that on Moore’s request, the campus police briefly detained Poddar, but released him when he appeared rational. They further claim that Dr. Harvey Powelson, Moore’s superior, then directed that no further action be taken to detain Poddar. No one warned plaintiffs of Tatiana’s peril (14).
Bridge Component | Program | Description/Commentary | Adaptation to Psychiatric Services |
---|---|---|---|
Superstructure: Clinician-Patient Level | |||
Patient and family engagement | Project RED, RARE, TCM | The goal is to achieve active and authentic engagement with the patient, the patient’s family, and other important sources of support and caregiving. One of the most important ways of doing so is to provide a written discharge plan the patient can understand. | Meaningful engagement in discharge planning, targeting recovery-focused goals, is required. Even if a patient lacks capacity, elicit the patient’s opinion and consider informed assent. Consider shared decision making. |
Comprehensive discharge planning and risk assessment throughout hospital stay | RARE, TJC | “Each patient and family/friend caregiver has a discharge risk assessment completed during the hospital stay, usually within the first 24–48 hours of admission. Discharge planning begins immediately after admission. During the hospital stay, patients are assessed for risk factors that may limit their ability to perform necessary aspects of self-care. Such risk factors include low literacy, recent hospital admissions, multiple chronic conditions or medications, and poor self-health ratings. Also, clinicians begin to assess risks that may be present at the receiving setting. For example, the clinician should confirm that the patient will have access to medications he or she needs at the next setting, as the pharmacy formulary there may not have the medications, or the ability to compound medications as ordered” (3, 25). | Risk assessment will help identify dynamic risk factors that can be mitigated, ranging from suicide and violence risk to supported housing and employment needs. Specialized issues also exist for discharge of the forensic patient back to the jail or prison setting. |
Assess patient’s degree of understanding of the discharge plan | Project RED | Use teach-back techniques to assess the patient’s understanding of the plan. This may involve shared responsibility with family members or other caregivers. | Assess the patient’s capacity to understand and follow through with TOC. |
Education | Project RED | Educate the patient about his or her diagnosis, discharge planning, and treatment. Meet with the patient, family, and other caregivers to provide education and begin discharge preparation. | Psychoeducation models can be individualized on the basis of patient factors, for example, the Program for Relapse Prevention (26) and coordinated specialty care for early psychosis (27). |
Medication reconciliation | Project RED, TJC | Review all medicine lists with the patient, including, when possible, the inpatient medicine list, the outpatient medicine list, the outpatient pharmacy list, and what the patient reports taking. Medications on these lists should include vitamins, herbal medicines, or other dietary supplements the patient takes. Explain what medicines to take, emphasizing any changes in the regimen. Review each medicine’s indication; how to take each medicine correctly; and important side effects and food interactions, if applicable. Ensure a realistic plan for obtaining medicines is in place. Assess the patient’s concerns about the medicine plan. | Standardize medication reconciliation in the outpatient mental health system, too. |
Assistance with medication self-management | CTI, guided care model, RARE, TCM | This includes education and promotion of self-management and medication self-management. | Shared decision making can further support medication adherence. |
Ascertain need for and obtain language assistance | Project RED | Assess preferred languages for oral communication and written materials. Once patient and caregiver English proficiency are determined, arrange for language assistance as needed, including translation of pertinent written materials. | Language assistance and cultural approaches are important not only for the patient but also for family members, proxy decision makers, and other caregivers. |
Plan for follow-up of pending lab or study results | Project RED | Identify the lab work and tests that have pending results. Discuss which clinician will be reviewing the results, as well as when and how the patient will receive information. | |
Make appointments for follow-up medical appointments and postdischarge tests and lab work | Project RED | Based on the follow-up needs (primary care and specialty), choose providers informed by patient preference—for example, in terms of gender, location, specialty, and health plan participation—and make follow-up appointments with providers and for tests with patient input for best time and date. Educate the patient on the plan and the importance of following through, then assess understanding. Inquire about traditional healers, and make an effort to reconcile traditional healing and conventional medicine methods so they are complementary. Assess any roadblocks to appointments (e.g., child care, transportation) and problem solve. | Care coordination of appointments, including scheduling coordination, can be helpful with or without the support of psychiatric case management. |
Organize postdischarge outpatient services and medical equipment. | Project RED | Coordinate medical equipment services with case management, including at-home services and social supports, in collaboration with the medical team and case managers. Document the arrangements in the discharge plan. | |
Crisis planning: Review with the patient what to do if a problem arises and develop a crisis plan. | Project RED, CTI, TJC | A pillar of Coleman’s CTI model is developing with the patient a list of red flags indicative of a worsening condition and instructions on how to respond to them. | Psychiatric advance directives can be a person-centered strategy to operationalize crisis planning and integrate such planning into the health care system. Wellness recovery action plans are recovery-based self-management systems that includes crisis planning (28). |
Timely follow-up, support, and coordination postdischarge | CTI | Follow-up appointments should be scheduled at the time of discharge to occur within seven days. | Individualize and integrate care to mitigate transition failures associated with follow-up appointments, including timeliness and access |
Bridge communication with the patient | TJC | Provide telephone reinforcement of the discharge plan. Bridge coordinators contact the patient within two days to conduct a secondary assessment and identify any needs. | |
Bridge coordinator and bridge support | Australian Southern Mental Health (29), CTI, bridge model, RARE | The bridge model supports contact with the patient within two days to conduct a secondary assessment and identify needs, as well as to provide additional tracking to address any emerging needs. Coleman’s CTI has transition coaches who foster care coordination and continuity of care via a series of visits and telephone calls. | Peer support specialists can serve as bridgers in a recovery-oriented program such as New York’s NYAPRS Peer Bridger Project (30) and Washington State’s RI Peer Bridger Program (31). Mental Health America provides a summary of peer bridger services (32). |
Multidisciplinary communication, collaboration, and coordination from admission through transition | TJC, RARE | Support both a culture of collaboration and standardization of handoff communication. | |
Readmission analysis | TJC | The treatment team should conduct a timely analysis of the readmission that involves the patient and family to determine possible causes for the rehospitalization, including financial, transportation, or caregiver problems. The analysis drives improvements for the TOC for the patient, family, friends, and caregivers. | Include in the readmission analysis a structured assessment of risk factors and risk reduction factors (resiliency), and target reduction of the dynamic risk factors and strengthening of resiliency in the treatment plan, discharge plan, and crisis plan. |
Substructure: Organizational Level | |||
Shared accountability | TJC, TCM | Clinician involvement and shared accountability during all points of transition. | |
Prospective modeling | BOOST, bridge model, TCM | The hospital identifies patients who would be most at risk for postdischarge complications and targets them with risk-specific interventions. Screening tools include the Society of Hospital Medicine’s risk assessment tool, the 8Ps (33), which can be used with the Project BOOST Program; the Canadian-developed LACE index (34); the computerized algorithm HOSPITAL (35) that focuses on medical TOC risk; the Pra instrument (36); and the United Kingdom’s PARR algorithm (37) and PARR–30 model (38) to identify patients at risk of readmission within 30 days (39). | A well-validated risk assessment tool focusing on persons with psychiatric illness with ability to adapt to setting and individual factors would be useful. Address comorbidity with behaviors, illnesses, and other risk factors, which may increase risk for failures in TOC—for example, history of rehospitalization, being a superutilizer, suicide risk, violence risk, treatment nonadherence, first-episode psychoses, high medical comorbidity, incarceration related to mental illness or alcohol or substance use, borderline or dependent personality traits, malingering, forensic considerations (e.g., those adjudicated not guilty by reason of insanity), or discharge against medical advice. |
Care pathways and specialized collaborative delivery care models | ACT, GRACE, TCM | The collaborative, integrated GRACE model targets low-income seniors with a team led by both a nurse practitioner and a social worker. TCM is a nurse-led, multidisciplinary model for chronically ill, high-risk older adults. | Develop clinical decision support and care pathways, individualized to local regions, that structure focused service options for high-risk populations as noted above under Prospective modeling, such as ACT access with fidelity. Consider assisted outpatient treatment if clinical and legal criteria are met (40). |
Support information transfer of patient health information | CTI | One of the four pillars of Coleman’s CTI model is “a patient-centered record owned and maintained by the patient to facilitate cross-site information transfer” (41) | Remove barriers to communication. Some corporate compliance infrastructure can err on the side of risk aversion and not allow communication of protected health information, which can increase safety risk and impair TOC. The U.S. Department of Health has released clarification of the HIPAA Privacy Rule as it relates to sharing information on mental health (42). |
Access to community-based services | TJC, CTI, guided care model | This involves organizational support of access with expectations of the standard follow-up appointment with a clinician within seven days of discharge (43). | In a setting with a shortage of psychiatric nurses and psychiatrists (44, 45), extenders may be used to attempt to bridge the gap and serve as leaders of treatment teams. The lack of access to psychiatrists may affect TOC for patients with severe mental illness (46). Access to psychiatric services within seven days postdischarge when clinically indicated—as well as other community-based services—should be an outcome measure expectation. |
Expedite transmission of discharge summary to clinicians accepting care of the patient | Project RED | Deliver discharge summary and After Hospital Care Plan to clinicians within 24 hours of discharge. | |
Quality measurement and feedback: Evaluate TOC measures and fidelity with procedures | TJC, ARC model, NTOCC | Gather data of key components of TOC and provide feedback to stakeholders on both side of the bridge, including patients, with the goal of improving quality in a culture of safety and learning. Use root cause analysis if a sentinel event associated with TOC occurs; use proactive risk assessment—for example, failure mode and effects analysis—to improve TOC; use lean management and other high reliability strategies. The Case Management Society of America convened the NTOCC to develop recommendations for TOC measures (47). | Use data to analyze opportunities for improvement at the clinician level but also the system level with consumer involvement. Outcome measures might include time to first treatment, time to first psychiatric appointment, show rates, crisis plan development rates, transfer of discharge summary information, medication reconciliation, 30-day readmission, and boarding of psychiatric patients readmitted. |
Standardized transition plans, procedures, and forms | TJC | Standardization should support clinicians in doing their work with fidelity to best TOC practices and not burden clinicians with wasteful steps and alert fatigue. | |
Standardized TOC training | TJC | Each organization defines successful TOC. Training targets the key steps in TOC with real-time performance feedback. TOC is made an organizational priority and a performance expectation. ACGME, medical school, nursing school, and all other health care education training organizations should include TOC competencies in their curricula as well as training in understanding the risks associated with transitions and how the learners can contribute to a safe TOC. | Support clinician training and competencies. Consider including key TOC elements in psychiatrist-focused and ongoing professional performance evaluations. The mental health system is often fragmented; therefore, standardize TOC for the mental health system and not just a single organization. |
Caregiver support | Guided care model | Assess caregiver needs and provide support. The model is designed to reduce family caregiver strain. | Caregiver strain is a challenge for family members and other caregivers. Reducing strain might thereby strengthen support. |
Foundation Level | |||
TOC research funding and support | NIMH, AHRQ | More controlled studies are needed on TOC, especially with a focus on serving persons with mental illness in psychiatric and other inpatient settings with attention to the effectiveness of the components and the system engineering elements. For example, although postdischarge telephone calls are widely used to reduce readmission rates, a systematic review by Crocker et al. showed that “despite the growing use of primary care–based telephone follow-up in the postdischarge period, there are no high-quality studies demonstrating its benefit” (48). | |
Standards and measures to support best practice integrated, collaborative | TJC, URAC, CMS | TJC enterprise is working on furthering safety and quality in TOC. However, accreditation organizations often only survey one organization within a system; the standards, elements of performance, and national patient safety goals are often siloed within accreditation programs. URAC supports integrated service models with standards. CMS has meaningful use core measures, which focus on TOC (49). Hospital-based inpatient psychiatric service measures that target TOC also exist, for example, actions such as creating a postdischarge care plan and transmitting that care plan to the next level of care provider upon discharge (50). CMS quality measures for 2017 merit-based incentive programs will include TOC measures (51) like postdischarge medication reconciliation and follow-up after hospitalization for mental illness. | TJC does have Behavioral Health Home Certification under its Behavioral Health Care Program (52). Additional efforts could occur in meeting the TOC needs of persons with mental illness within all programs. Challenges exist with surveying TOC if one organization is accredited and others are not. |
Fund best practice models for TOC | The CMS Quality Improvement Program will use merit-based incentive programs and advanced alternative payment models to reimburse (53). | ||
Fund integrated and collaborative care with incentives for TOC conditions of participation, standards, and outcomes | The collaborative care model of integrating primary care and behavioral health has several core components that could ensure safer TOCs, including a behavioral care manager, a registry to track engagement and progress, and a weekly caseload review between the care manager and a psychiatric consultant to make treatment changes for patients who are not improving. | Although the collaborative care model has been around for 15 years, no consistent funding mechanisms have been available, which has been a significant obstacle to widespread adoption. However, beginning January 1, 2017, new CPT codes are available to fund this model, and more implementation is anticipated as these codes start first with Medicare and then experience more widespread adoption in Medicaid and private payer sectors. |
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