FOLLOW-UP AFTER HOSPITALIZATION FOR MAJOR AFFECTIVE DISORDER

Planning and Communicating at the Time of Discharge

Ensuring continuity of care for hospitalized patients who have serious behavioral health conditions is a difficult but important challenge. This plan's success in meeting this challenge was helped immensely by a push from internal clinical champions to improve performance.

A HEDIS measure had been developed that looked at ambulatory follow-up after hospitalization. The measure was developed because recent studies had demonstrated adequate early post-discharge management was effective in reducing early rehospitalization in patients with depression.

The plan's behavioral health providers were concerned that their HEDIS performance was subpar. Seeking to show the value of the in-house department over a behavioral health carve-out, staff focused on patients who had been hospitalized for major affective disorder.

HEDIS 2.5 (and 3.0) methodology was used throughout this activity. The targeted population consisted of all commercial members age 18 through 64 years who were hospitalized for treatment of major affective disorder. Both medical record and administrative information were used to determine a rate for this entire population.

Baseline data from 1994 indicated that 79.9% of plan members admitted for depression in the previous year were seen in ambulatory settings within 30 days after discharge. For a benchmark, the plan chose a rate of 90%. (This rate was the best reported by any plan within the national organization.) The behavioral health staff set their performance goal at 92%.

The regional psychiatry chief and departmental operations analyst reviewed the available data to determine barriers to improvement. Their analysis showed that, although some members failed to keep appointments that had been made, many members who were lost to follow-up made no appointment at all.

Discussion with providers made it clear that they had difficulty in determining which patients were due for an appointment and in tracking those who missed or cancelled their visits. The providers felt that if patients could be tracked centrally for appointment status, then they could concentrate instead on the appropriate care for each individual.

The plan concluded that it needed to develop a better means of monitoring members to ensure that they made and kept appointments, particularly those members being followed in community behavioral health centers. As a result, it implemented one specific intervention in 1995 to improve its follow-up rate - it faxed discharge summaries to the administrative office of the behavioral health department immediately after each patient was discharged. A tickler system based on these discharge summaries was developed to monitor whether patients were seen within 30 days after discharge.

TICKLER SYSTEMS Interventions don't need to be fancy or complex to be effective. A simple system to ensure communication and follow-up yielded great results in this plan. Tickler systems can be used with a variety of interventions. Often underused, they don't even need to be computerized. Sometimes simple file and reminder card systems can work wonders.

The first remeasurement, using 1995 data, showed that the initial intervention had been very effective; the follow-up rate for 1995 was 88.9%, a significant improvement. The behavioral health department felt that the raw data still supported the hypothesis that many members who were lost to follow-up had never made an appointment. Therefore, the plan initiated follow-up appointment scheduling at the time of discharge. Members were then entered into a database and tracked to ensure that they kept the scheduled appointment. This system allowed staff to regularly monitor whether those patients identified were seen within 30 days following discharge.

The combination of interventions seemed very effective. The plan reported 1996 data that demonstrated a follow-up rate of 93.9%. Although this was not a statistically significant change over the prior year, the plan had met its goal and maintained its improvement.

This plan has continued its efforts for improvement. Guidelines for follow-up for all behavioral health disorders have been adopted and scheduled for periodic review.

Appointment confirmation at time of discharge, tracking, and communication with outside providers have been addressed. Outpatient clinicians have been used to contact patients who don't keep their appointments. Staff reviews this information on a monthly basis to identify system problems.