REDUCING INPATIENT MENTAL HEALTH READMISSIONS

Reengineering Case Management

Members readmitted to inpatient mental health treatment are those who suffer the most from psychological and emotional distress. These patients may show more severe or persistent illness, or a history of noncompliance with a treatment regimen. This plan noted that members with affective disorders constituted over 60 percent of this population.

Factors that affect readmission include outreach to the member and coordination of after-care. Member outreach can motivate members to keep outpatient appointments, increase social support and increase compliance with medication regimens.

To address these needs, the plan developed a case management program for members at risk for readmission. This program focused on a number of issues:

• The development of strong social supports
• Crisis intervention
• Monitoring of medication compliance
• Attendance at aftercare appointments
• Linkages to aftercare providers
• Coordination among multiple providers

A proxy measure of the effectiveness of aftercare coordination and outreach is readmission to inpatient care. Because performance in this area was felt to be less than desired, the plan decided to embark on a quality improvement activity. It hoped to positively affect member outcomes by reducing readmissions with improved processes of linkage, monitoring and outreach.

COORDINATION OF CARE Despite having a case management system for many years, the plan found that potentially preventable readmissions were still occurring. One problem was that case management services were divided between inpatient and outpatient teams. The patient was "handed off" from one team to another at time of discharge. This fragmentation of services was thought to contribute to readmission. Another problem was that every case manager was a "jack of all trades," providing all needed services to patients in all geographic areas.

The plan targeted all members age 18 to 64 with a diagnosis of major affective disorder who were discharged from inpatient care during the reporting period.

The performance measure selected was the percentage of the targeted population who had been readmitted, for a diagnosis of major affective disorder, within 90 days of discharge.

The plan used data from its authorization system. Baseline performance, based on 1997 data, showed a readmission rate of 15.4 percent. The plan set a goal for readmissions at 13 percent or less. The clinical director, QI director and medical director analyzed data from baseline performance and a number of data sources.

Analyzing the medical records and authorization data of readmitted members showed:

• 39 percent of readmissions occurred within 14 days (72 percent of these occurred within five days)
• Members using more than 20 inpatient days per year were rehospitalized an average of three times
• Borderline or dependent personality disorders were prominent
• The patient often had multiple providers

Analysis of case management charts showed three commonly cited reasons for readmission:

• Medication noncompliance
• Inadequate support systems
• Lack of ambulatory follow-up

Based on these analyses, the Quality Improvement Committee identified five major barriers as opportunities for intervention:

• Lack of compliance with treatment regimens such as medication and aftercare appointments
• Lack of social supports
• Lack of a methodical system for identifying and interviewing newly discharged members
• Lack of an effective system to link members with their aftercare providers
• Lack of regular and ongoing communication with newly discharged members

The plan decided that it needed to redesign its case management program. It needed a program that would identify members most at risk, and promptly meet their identified needs.

It first determined that the reorganized case management services should focus on those who had three or more admissions, those who had exhausted their mental health benefit, and those who had used 20 or more inpatient days in the last year.

BENEFIT LIMITATIONS In many cases, these members' benefits were exhausted or nearly so. After exhausting their commercial benefits, they entered the public sector until a new benefit year came around, when they reentered the commercial sector. This resulted in fragmentation of care. (At the time of this activity, there was no parity for mental health benefits in the states served by this plan.

A written case management plan was developed for all patients (included in QP Tool ).

Case managers were organized into teams, divided by geographical region. Each team contained specialists in certain areas:

• Outpatient specialists performed referrals
• Inpatient specialists performed inpatient utilization management
• Special services personnel focused on crisis management and treatment plan review

By making each team responsible for a group of patients, the fragmentation caused by the "handoff" at time of discharge is avoided. All patients are entered into the team's patient log (included in QP Tool ).

Members are introduced to the case management program and to their case manager through written materials (included in QP Tool and QP Tool ).

At discharge, an ambulatory follow-up appointment is confirmed. If the appointment is missed, another one is scheduled.

Member outreach is accomplished with telephone calls and letters to motivate members to keep appointments and comply with medication regimens. Calls start out weekly, and are gradually decreased over time, based on member needs.

The team coordinates care across multiple practitioners such as psychiatrists and psychologists. (A sample form for consent to release member information is included in QP Tool .)

The team also refers patients to community resources such as support groups, and provides crisis intervention.

The plan's medical director was excited about the new program. He discussed the program with practitioners and with clinicians on committees. He interacted with individual clinicians to explain that the purpose of the teams was not to provide care, but to act as advocates for members and practitioners to facilitate necessary care.

The involved clinical departments formed work teams to address specific issues related to implementation of the new system. Changes and revisions to the program were discussed and reviewed at staff meetings.

DIFFERING MEASUREMENT PERIODS This plan altered its measurement period: the baseline year reflected the calendar year 1997, while the first remeasurement period was April 1998 to March 1999. This change was made in order to ascertain the effect of the case management reorganization, which was not entirely implemented until the first quarter of 1998. It was important that the plan continued to use a 12-month period, as major affective disorder is known to exhibit seasonal variation. Caution needs to be taken when changing measurement periods to preserve comparability.

The first remeasurement, based on data from April 1998 to March 1999, documented a readmission rate of 10.8 percent, a statistically significant improvement that exceeded the plan's goal.

The plan has continued its case management program, enhancing and expanding it. It determined an optimal number of 25 to 40 members per case manager (depending on the severity of the members' disorders).

An aftercare specialist was added to each team. This individual is responsible for linking newly discharged members with aftercare providers, providing outreach and documenting aftercare efforts.

As the most at-risk patients became better managed, the case management program was expanded to include additional patients:

• Patients with two admissions
• Patients with a history of hospitalization precipitated by noncompliance
• Patients with a complicating medical condition
• Patients with eating disorders
• Patients with other complex situations

The readmission rate for 1999 was 12.5 percent, not statistically different from the 1998 rate.

The plan notes that the case management department is a special group of individuals dedicated to the program. The continuing efforts of this group, supported by resources within the organization, makes it possible for patients with an affective disorder to take better care of themselves and to stay out of the hospital.