FOLLOW-UP AFTER HOSPITALIZATION FOR MAJOR AFFECTIVE DISORDER

Improving a Vendor's Discharge Planning

Preventing hospital readmission can not only be cost effective, but also a good indicator of improved quality. This plan discovered that behavioral health disorders were associated with the plan's highest readmission rates. Yet, it was unable to track members treated by its behavioral health vendor's network. In order to identify the reasons for high rates of hospitalization and readmission, it partnered with its vendor to establish a patient tracking system.

The plan and its vendor identified the need to establish a formal patient tracking mechanism that would assist patients in the transition from inpatient to ambulatory care. This program helped ensure that members continued to receive appropriate, individualized treatment after leaving the hospital. The benefit to members: a reduced risk of readmission and an improved quality of life.

The plan used HEDIS 2.5 (and 3.0) methodology throughout the activity. The targeted population was all members discharged from an inpatient facility with a diagnosis of major affective disorder. The plan used hospital inpatient discharge summaries and the UB-92 form to identify these members. The measurement used was the HEDIS 2.5 measure of ambulatory follow-up after hospitalization for major affective disorder. The plan used encounter data to identify those who received the appropriate follow-up care.

HEDIS 3.0 revised this measure to include selected behavioral health disorders besides depression. 1996 data were analyzed using both HEDIS 2.5 and 3.0 specifications to allow for year to year comparisons with both previous and future measurements.

The plan used 1994 data to establish its baseline ambulatory follow-up rate for major affective disorder as 55%. As a benchmark, the plan used 78.2%, the regional average as reported in NCQA's Quality Compass. The plan's staff set a performance goal of 85% for its ambulatory follow-up rate.

Without any system to track patients receiving behavioral health care, no real barrier analysis was possible. The plan and its vendor agreed that implementing a tracking system was the first needed intervention.

New discharge planning and follow-up procedures were put into place between June and December 1995. The vendor established a computerized clinical authorization system based on data entered by care managers, including chart review data. This system also gathered information to identify specific reasons for patient noncompliance with treatment. The vendor created a new staff position - a clinical team care manager - to help implement the new system. The plan and the vendor collaborated closely to implement formal procedures for tracking members who had been hospitalized for behavioral health disorders:

• the clinical team care manager discussed the patient's discharge plans with the treatment facility within 48 hours of admission
• the clinical team care manager notified the clinical support staff of the proposed discharge plan at the time of discharge
• the clinical support staff assisted patients in scheduling follow-up appointments within three days of discharge
• the clinical support staff monitored patient compliance with treatment by contacting the outpatient provider within two weeks after discharge
• if the patient was not compliant in keeping the scheduled appointment, the clinical support staff referred the case back to the clinical team care manager

The vendor monitored follow-up rates and readmission rates on a quarterly basis to evaluate the effectiveness of these procedures and to make necessary adjustments.

TRACKING SYSTEMS You can't manage what you can't measure. Before any strong interventions could be taken by this plan or its vendor, they needed information about the targeted population. A well-designed tracking system proved to be the key to success. If systems don't provide the needed data, a key strategy to quality improvement may be to improve the data systems.

The first remeasurement, based on 1995 data, demonstrated a rate of 73.3%, a statistically significant increase from the baseline measure of 55%. The discharge planning and follow-up procedures appeared to make a difference. The plan set a new performance goal of 90%.

The vendor began to focus on educational activities for its members and providers. It published an article on depression in the member newsletter entitled, "Learning to Cope With Stress," and also published articles in the provider newsletter such as "Identifying Depression: What Every PCP Should Know" and "Traumatic Events Can Change Your Life! Treat it Early!" It also hired additional care managers.

The health plan hired an epidemiologist to assist in study design and analysis. The plan also held a CME seminar on depression for primary care physicians and behavioral health providers.

The second remeasurement, based on 1996 data, produced a follow-up rate of 78.2%. This was not a statistically significant change from the previous year, but it was a statistically significant change from the baseline rate. The plan decided that its previous goal of 90% was perhaps overly ambitious, and set a new, more realistic goal of 80%.

As a result of implementing the tracking system, improved clinical data allowed the plan and its vendor to document and identify specific reasons for patient noncompliance. They determined that 30% of the reasons for noncompliance involved follow-up care with nonnetwork providers. The plan also identified some problems with accessibility to the vendor's network. These data caused an increased focus on access. New efforts in 1997 were devoted mainly to expanding the network.

An analysis of noncompliant cases in 1997 showed the most (57%) of the patients without follow-up failed multiple rescheduled appointments; 10% of these patients cited transportation problems. The vendor hired a follow-up specialist to perform drill-down analyses on the reason for noncompliance and to assure individual follow-up as needed.

The MCO has asked the vendor to supply data on readmissions. It hopes to determine the impact of improved follow-up on readmission rates.

In today's health care world, even the best of relationships can prove fragile. The vendor has recently been acquired by another organization. The plan's challenge is to ensure high priority for this initiative.