FOLLOW-UP AFTER HOSPITALIZATION FOR MAJOR AFFECTIVE DISORDER

Establishing a Zero Defects Tracking Process

High volume isn't the only criterion for deciding the relevancy of a quality improvement (QI) activity. This health plan considered the importance of behavioral health services and risk factors for readmission to an inpatient care setting. Measuring its progress using a HEDIS measure, the QI team implemented a number of processes. These processes ensured that members hospitalized for depression would receive timely follow-up care in the ambulatory setting.

As early as 1990, the health plan was concerned with continuity and coordination of care for behavioral health services. Also called into question: the consistency with which the plan handled referrals to appropriate levels of care. Because data that examined follow-up care had never been collected or analyzed, the plan's only indication of the extent of any potential problems came from concerns expressed by its staff.

These concerns led the health plan to devote significant resources to the establishment of a staff behavioral health unit. Ultimately staffed with a psychiatrist/medical director, two case managers, and administrative support, this unit provided oversight of behavioral health practitioners and inpatient facilities. Case review conducted during the unit's formation demonstrated that there indeed were considerable variations in the handling of cases.

In 1993, HEDIS 2.0 was published. It included the quality of care measure entitled "Ambulatory Follow-up After Hospitalization for Major Affective Disorder." In discussing the rationale for the measure, HEDIS 2.0 noted that up to 5% of the population may suffer from depression at any one time. Problems of underdiagnosis coexisted with inpatient overutilization. The measure was selected because recent studies had demonstrated adequate early postdischarge management was effective in reducing early rehospitalization in depressed patients.

The QI team and the behavioral health unit began to measure their performance, establishing a baseline for their QI efforts.

The plan used HEDIS 2.0 (and as they were released, HEDIS 2.5 and 3.0) methodology. The target population consisted of members between the ages of 18 and 64 years at the time of discharge, with a principal ICD-9-CM diagnosis code indicating major affective disorder (296.xxx). The data were obtained using information from claims and encounter forms together with the behavioral health unit's documentation.

The plan used HEDIS data specifications to measure the percentage of the above population who received ambulatory follow-up within 30 days of discharge. Baseline data from 1994 revealed that only 53% of discharged members were being seen within the critical 30-day time window. The anecdotes of problems with continuity had proven true. The plan had discovered an opportunity to improve continuity in behavioral health care.

The QI team then set about establishing a benchmark and a performance goal for its efforts. A large health plan competing in the plan's market was being recognized nationally for a groundbreaking effort in publishing performance measurement results. This plan had reported a follow-up rate of 70%. Using this benchmark, the QI team established its own performance goal: 80% of patients who had been hospitalized for major affective disorder could complete a follow-up ambulatory care appointment within 30 days of discharge.

In the first half of 1995, the health plan began its intervention. Staff from the behavioral health unit developed and implemented hospital performance standards. These comprehensive standards addressed:

• Discharge planning (a sample form is included in QP Tool )
• Information releases
• Communication with primary care physicians (PCPs), behavioral health providers, and facilities (the communication standards and forms are included in QP Tool )
• Appointment documentation
• Discharge summaries

SCALABILITY For larger plans, this project would be resource-intensive because it would mean concurrently managing the entire population of patients hospitalized for major affective disorder. Plans might choose to rely instead on retrospective review of the transition from inpatient to outpatient care. Although this may be a reasonable and cost-effective approach, it may make it difficult to achieve the results reported in this profile.

The first remeasurement, based on 1995 data, was encouraging: the rate of follow-up appointments had increased to 73%. This change was found to be statistically significant.

Yet, the plan was still short of its goal of 80%. It began to conduct a barrier analysis to determine appropriate additional interventions. Staff reviewed every case of hospitalization for a behavioral health diagnosis. They uncovered barriers to both continuity of care and data collection. These included causes as diverse as exhausted outpatient behavioral health benefits, care that had been rendered by out-of-plan providers, and inconsistent discharge planning guidelines.

Realizing that it had no consistent method of tracking members admitted to behavioral health facilities, the behavioral health unit introduced a simple and effective behavioral health case-management tracking process. Case managers began to monitor continuity of patient care using a simple, internally developed form. This tracking sheet helped to ensure that the same elements of care were being assessed consistently. It spanned an episode of care from the point of admission through the ambulatory posthospital follow-up visit. The form recorded scheduled appointment dates, whether the appointments were kept, and any other pending referrals.

Coordination of care was further enhanced by persuading behavioral health facilities to adopt uniform discharge planning standards.

The second remeasurement, based on 1996 data, demonstrated a zero defects level of performance - the plan had achieved a 100% rate of follow-up appointments!

Not only did 1996 data reveal a 100% rate of follow-up appointments, but results from 1997 show that the plan held its gains, maintaining a 100% follow-up rate.

The plan did not stop its QI efforts in behavioral health, despite exceeding its performance goal. It began to examine other important aspects of ambulatory follow-up care. It communicated with its physicians and behavioral health providers through articles in the provider newsletter in spring of 1997 and winter of 1999. In 1998, the behavioral health unit's QI team sent a questionnaire to PCPs to determine types and time frames for needed communications. Based on the results, the plan:

• Distributed new communication standards revised to fit the preferences of PCPs
• Created new forms to facilitate communication among behavioral health personnel, inpatient facilities, and PCPs
• Visited medical groups with delegated utilization management to ensure consistency
• Distributed copies of a newly developed directory of PCPs' and behavioral health providers' fax numbers to all inpatient facilities

This work to improve communications continues the health plan's QI efforts. Continuity and coordination of behavioral health care remain important aspects of care for this plan, as they strive for continued and meaningful improvement.

ZERO DEFECTS A 100% follow-up rate may be difficult to maintain. Should this plan grow significantly, scalability of the intervention may become an issue. Nevertheless, a maintained 100% follow-up rate is a strong indicator of a successful process.

CLINICIAN INVOLVEMENT Clinicians can be difficult to involve in QI activities, particularly during early stages. Nevertheless, early recruitment of "clinical champions" can result in immense improvement in the quality of interventions.