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F2F Follow Up Within 7 Days of an Mental Health Inpatient Discharge
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F2F Follow Up Within 7 Days of an Mental Health Inpatient Discharge

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Re-admissions related to mental health and addictions are high cost items for CMS and likely to get further attention. Preventing avoidable hospital re-admissions is considered by many to be the most …

Re-admissions related to mental health and addictions are high cost items for CMS and likely to get further attention. Preventing avoidable hospital re-admissions is considered by many to be the most important opportunity for reducing waste in health care. The transition from the inpatient to the outpatient setting is a critical point along the care continuum in which there is a real opportunity to prevent re-admissions. Targeted Case managers will required to meet face-to-face with individuals within seven days after an mental health inpatient discharge. Targeted case management support in the days following hospital discharges are an effective deterrent in preventing some avoidable hospitalizations. Analysis indicates that targeted case management face-to-face follow-up in the 90% to 94% range for the time frames tested.


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  • 1. F2F Follow Up Within 7 Days of an Mental Health Inpatient Discharge Greg McCutcheon, MA MH Services Director
  • 2. MH Goal 1Targeted Case managers will meet face-to- face with individuals within seven days after an inpatient discharge including all acute IP psychiatric, any state mental hospital, and Philhaven extended acute care.
  • 3. What Are the Findings?• Random sampling of 49 adult hospitalizations showed 90% compliance with F2F follow-up with 7 days• Primary reason for not meeting the criteria was the inability to locate the individual after the hospitalization• CBHNP found that 94% of individuals received CMU TCM service within 7 days.
  • 4. You Don’t Know Jencks…• Stephen F. Jencks, M.D., whose April, 2009 article in the New England Journal of Medicine set the tone for todays readmission prevention energy.• His review found that nearly 21%, or one in five, were re-hospitalized within 30 days and 34% were readmitted within 90 days.
  • 5. What Did Jencks Find?• One stunning finding from Jencks was that little more than half of patients readmitted to the hospital within 30 days of discharge had no evidence of a follow-up visit of any kind between discharge and readmission
  • 6. Hospital Readmission Within 30 Days of Discharge a Major Issue• CMS focused on reducing readmissions for heart attacks, heart failure and pneumonia• The Medicare Payment Advisory Commission recommended a payment strategy to penalize hospitals with high readmission rates that was included in the Affordable Care Act (ACA)• Readmissions related to mental health and addictions are high cost items for CMS and likely to get further attention
  • 7. Readmissions Increase Cost of Care• Unrelenting rises in health care costs has created a renewed and more urgent push for “bending” the cost curve• Inpatient services are generally the largest expense• Preventing avoidable hospital readmissions is considered by many to be the most important opportunity for reducing waste in health care
  • 8. What Causes Readmissions?• Readmissions in the immediate post- hospital discharge period are more likely to be related to care during the hospitalization• They may also be due to failures in the transition of care between the hospital and outpatient setting
  • 9. Transitions• The movement of patients from one care setting to another offers many opportunities for quality improvement.• Hospital discharges are a critical transition point in care that leaves many patients vulnerable to lack of support, resources and readmission.• These “transition” points contribute to unnecessarily high rates inpatient use and healthcare spending and expose some individuals to lapses in quality and safety
  • 10. Why Is Follow-Up Important?• The gap between the percentage of readmissions and the percentage of potentially avoidable readmissions widens as the number of days increase• This suggests that efforts to prevent avoidable readmissions should target discharge planning and the time immediately following discharge.• The transition from the inpatient to the outpatient setting is a critical point along the care continuum in which there is a real opportunity to prevent readmissions
  • 11. Opportunities for Real Impact• Front-loading the number of home visits immediately after discharge• Improving patient transitions between care settings• The term “discharge” has a bad connotation• “Transition” infers a sense of accountability between both the giving and receiving parties
  • 12. An Ounce of Prevention• Doing things correctly day-in and day-out• Preventing the initial admission helps to reduce readmission rates.• The most effective way to prevent readmission is to prevent the hospitalization in the first place
  • 13. QUESTIONS?Thank you for your time and attention Greg McCutcheon, MA MH Services Director CMU (Case Management Unit) 1100 South Cameron Street Harrisburg, PA 17104 gmccutcheon@cmu.cc