Reducing hospitalisations and arrests of mental health patients through the use of analytics and care co-ordination

Editor's Notes

• #4 As the chair of a state task force on substance abuse and mental health issues in the courts stated to the US House of Representatives, “Because community-based service delivery systems are often fragmented, difficult to navigate, and slow to respond to critical needs, many individuals with the most severe and disabling forms of mental illnesses who are unable to access primary and preventive care in the community eventually fall through the cracks and land in the criminal justice or state hospital systems where service costs are exponentially higher and targeted toward crisis resolution and restoration of competency, as opposed to promoting ongoing stable recovery and community integration. As a result, instead of investing in community-based prevention, treatment and wellness services, states and communities are increasingly forced to allocate limited mental health funding and resources to costly crises services and inpatient hospital care in both the civil and forensic mental health systems.” Additionally, research from the National Institute of Corrections suggests that people with mental illness are overrepresented in the criminal justice system by rates of two to four times the normal population. The severity of illnesses varies, but advocates say that one factor remains steady: with proper treatment, many of these incarcerations, and reincarcerations, could be avoided. This specific client is a large behavioural healthcare network of 52 mental health service providing organizations that came together to provide a coordinated system of behavioral health care within the community. With their non-integrated service delivery for mental health this network reflected the US figures of almost 10 percent of patients discharged from state psychiatric hospitals are readmitted within 30 days, and 20 percent more are readmitted within 180 days.
• #5 This behavioral healthcare network’s goal was to develop, implement and refine a coordinated system of behavioral healthcare that enhances prevention, treatment and recovery services for those at risk of or who suffer from mental health and substance abuse problems. The largest county it serves has one of the highest proportions of mentally ill people in the United States at three times the national average, making it ground zero for finding and implementing a smarter mental healthcare solution. Although it has a network of mental healthcare providers, individual treatment and follow-up care can still be disjointed and confusing. For example, if a person experiencing a mental health crisis is admitted to a mental health facility, he might be diagnosed with bipolar disorder, receive some medications and a referral, and be discharged within 72 hours. If the patient doesn’t follow up on the referral or doesn’t take his medication, he may shortly end up in crisis again and be admitted to a different facility that doesn’t have access to his previous treatment records. The patient may be given the same or even a different diagnosis and medications, be discharged, and begin the cycle again. In fact, that person may eventually experience a mental health crisis and commit a crime or be picked up by police, resulting in what should have been preventable incarceration.The organization wanted to treat patients holistically to help ensure the best patient outcomes, but without integrated records or a systematic way to provide and follow up on referrals, the network had no way to ensure continuous, integrated care for the mentally ill. For example, because they had no way to analyze which providers would meet each patient’s needs, referring providers often made treatment referrals based on their own familiarity with other facilities or out of habit. This mode of mental healthcare provision had become costly to the healthcare network, to the county and, most important, to the patient.
• #7 IBM piloted a coordinated care and healthcare analytics solution from IBM and IBM Client Partner Otsuka Pharmaceutical Co., Ltd. The solution is designed to help mental healthcare organizations provide a nearly seamless mental healthcare delivery system that can improve patient outcomes and reduce hospital readmissions as well as reincarcerations. IBM brings care coordination software, sophisticated information management, big data and analytics capabilities, and strategic consulting experience in healthcare analytics to the table. Otsuka Pharmaceutical contributes a deep understanding of neuroscience, the mental healthcare industry and delivery system dynamics.
• #8 A Care Management solution built on the Cúram Social Program Management platform lets the network manage patient care services anywhere within the network. A single patient record follows patients as they receive services from any network provider. When a facility discharges a patient to another provider, the receiving provider automatically gets the record before the patient arrives. By providing complete patient information to the right providers at the right times, the solution helps eliminate duplication of intake efforts, reduces multiple or conflicting diagnoses, and lowers the chances of providers missing critical patient information. Even when a patient has multiple hospital admissions or transfers from one provider or facility to another, the solution integrates the patient’s data to give everyone a holistic patient view. In addition, the solution creates provider accountability that the previous manual patient handoff system did not have. In the past, once a patient left a facility, the facility didn’t follow up on whether the patient ever made it to the new provider, and sometimes the new provider was never notified that the patient was coming. Up to 50 percent of referred patients didn’t make it to their follow-on care, and no one was looking for them. Now, if a patient is referred to behavioural counselling services but does not keep his appointment, both the referring and receiving providers are notified and can follow up with the patient to ensure that he receives the care needed.
• #9 In addition to creating a unified, more comprehensive patient health record, when a patient needs a referral to another provider, the system analyzes provider and patient information to recommend providers for the patient. There is a dashboard interface that presents the recommendations to the referring provider, allowing it to choose the best fit for the patient. Once the patient is assigned to a facility or provider, the solution enables the referring facility to notify the receiving facility about the referral. The receiving facility can immediately access the patient’s information and prepare for his arrival and even create a treatment plan before the patient arrives. The solution also helps the network better evaluate its providers’ performance. As a publicly funded organization, the network must carefully use and account for money spent on service provision. Previously, the providers sent monthly reports outlining the services provided and how much they should be paid. These reports lacked detail and gave only a big-picture view of services. The dashboard lets the network see, in near-real time, exactly what services it is getting for its money. For example, if a patient is receiving psychotherapy one hour every two weeks for six months, then the provider should be billing for the exact number of sessions given. As the solution continues to collect and integrate more and better data, the network can use the software to evaluate the effectiveness of its providers. Analysis can help it identify which characteristics make one provider better at treating schizophrenia and another better at treating bipolar disorder in particular groups of patients and use this insight to improve services among its provider network. Finally, analysis of patients that consume the most mental health services can help the network identify the characteristics and predictors that make these patients more vulnerable. The network hopes to gain insight into these factors, whether they are social, medical or demographic, to help predict which patients need more intervention and services up front to prevent future hospitalizations or incarcerations.
• #10 David is a homeless man, in his mid-thirties who has battled schizophrenia since the age of 17.  He has no family support and has lived on the streets much of his adult life.  When David is medicated and receiving treatment, he does reasonably well (stays out of jail, able to manage his own care, stays focused on daily activities).  Once an acute episode is resolved, he begins to drift as he does not have the care he receives during crisis.  When this happens, he usually ends up at a crisis intervention center or in jail.  In a crisis intervention center, he usually gets immediate treatment that begins a stabilization process.  But at the end of that acute treatment, he is given a referral for outpatient follow-up and released back into his own care.  This creates a continuous negative cycle. This fragmented and episodic way of treating David leads to him showing up at facilities three or four times a year.  His records are maintained at the institution level so it is difficult to obtain the full history of diagnoses, medication, treatment records and case history in a timely manner or if at all.  This disjointed system results in multiple gaps in David’s care – clinical decisions are made based on immediate symptoms, without knowledge of his history. Shortly after arriving in one of the cities covered by our client network, David is picked up by local law enforcement for disorderly conduct.  First responders there have been trained and equipped with a short assessment providing them information to help direct whether David should be taken to the emergency room, the jail or a crisis intervention center.  The officers determine that David should be taken to the nearest crisis stabilization facility.
• #11 At the crisis stabilization facility David meets with a team of care provider that reviews his history and completes an assessment.  He begins treatment to address his acute symptoms. Based on the results of David’s assessment, an individualized care plan addressing his clinical, behavioral and social needs is developed to support him.  The care team can assess resources across the network and determine next stages of care.  A referral is made to a system provider to facilitate outpatient care and there is a clear and accountable hand-off from the acute care setting at the facility to the physicians, nurses, and social workers that will be part of his ongoing care team.  Here, he receives a detailed, individualized care plan.
• #12 David’s care plan includes clinical and behavioral intervention such as medication adherence & ongoing counseling.  It also contains activities to help him overcome the social barriers to health and well-being.  His case worker is able understand and enroll him in available programs.  His status as a homeless man puts him at a higher risk of relapse so his case worker ensures that he is placed in a relatively short term residence that will provide food, clothing, and transition services for David while he waits for an opening in a more stable housing environment.  He is also provided transportation vouchers so that he can get to his medical appointments, support group meetings and the pharmacy to renew his prescriptions. His caseworker also helps him apply for longer term services such as government sponsored food and medical assistance. Within a day of discharge, David meets with his psychiatrist at the community clinic to review how he is responding to his medication.  He also meets with his counselor for his bi-weekly 30 minute behavioral therapy session.  The clinicians are able to record David’s visit and progress against the original treatment plan, receiving insight from their clinical notes.  This allows the care team members to collaborate in real time and is a powerful tool for David’s caseworker as she will be alerted immediately if David begins missing appointments.   David’s primary risk factors, medication and adherence to treatment plans, are closely monitored by the care team and his caseworker is notified if David begins to become non-compliant or other key indicators that care givers should intervene. It is also important for David’s care team members, like his psychiatrist and his therapist, to collaborate on David’s care.  Like David’s caseworker, they are able to view his attendance and his progress on the various items on his plan.  They are also able to collaborate through a secure portal that allows them to communicate with each other regarding David’s progress and situational factors that influence his outcome.
• #13 Running in the background of the system, insight on the assessment and plan comes from advanced analytics and data mining.  The system identifies modifiable risk factors for individuals with David’s diagnosis and looks for patterns of behavior and interventions that are indicative of impending crisis.  This supplements the knowledge and experience of the care team. 
• #14 As David progresses, he is reassessed.  The support he has received has made a huge difference in David’s health and well-being but he is not yet self-sufficient.  His course of therapy can now shift to long term goals, instead of short term stabilization.  David’s latest assessments indicate he is stable enough to take the next step and a referral is made for a job skills workshop and a community sponsored work program.  Care providers document David's short and long term goals Based on these goals, it is recommended that David receive additional services to help secure longer term housing and further employment training
• #15 Real business results- Helps reduce the probability of re-arrest for mental health patients in crisis by 30 – 50 percent if they receive integrated behavioral health services within 90 days of initial arrest- Lets providers make patient-specific referrals that can positively influence the patient’s treatment outcome- Provides near-real-time visibility into and analysis of service provider activity to help the network spend public money more effectivelyThe solution pulls patient demographic information, care management history and diagnosis information to provide a unified patient record. Integrated patient and provider data provides a single treatment view that follows the patient throughout the network.  Analytics let the provider network make patient-centric treatment recommendations and provide deep insight into patient risk factors and crisis patterns to help it predict and prevent mental health crises that can result in hospitalization or incarceration. this large behavioral healthcare network improves its ability to provide integrated and consistent mental healthcare to the residents of the counties it serves. The solution helps replace manual, intuition-based follow-up care referrals with informed recommendations based on patient-centric analysis. Analytics further help the healthcare network evaluate the treatment- and cost-effectiveness of its providers, ensuring that public money is allocated in the best way possible, while patients receive outstanding care. Finally, the solution can help predict and prevent mental health crises by analyzing both the individual patient who might be off his medication and which patients are at highest risk of future mental health issues, helping the network get in front of the problem through intervention and preventive service provision.