Behavioral Health
Inpatient Psychiatric Facility Collaborative Newsletter
April 2018

 
Recommendations for Care Transition Support (Part I)
  
The period of transition between healthcare settings is a vulnerable period for patients and families. Navigating a fragmented healthcare system is complicated, especially without adequate knowledge and support. Care transition support is needed to help patients and family members successfully transition from one care setting to another

Recommendations for Patients with Mental Illnesses:
 
Post-hospitalization follow-up:
  • The patient should have a follow-up appointment with a provider of mental health services. Ideally, this appointment should occur within seven calendar days following hospitalization, to review their progress and plan of care (sooner if their condition warrants).
  • For new referrals, facilitate the connection between the patient and the agency to which the patient is being referred to ensure a successful connection.
  • The receiving mental health provider should have a system to accommodate availability for transitioned patients within seven calendar days.
  • All patients with mental illnesses and chronic or acute physical problems should have an appointment scheduled with their medical provider prior to discharge from the hospital.
  • An adult patient with mental illness who does not have a designated primary care provider, should be connected to one and an appointment made within 60 days for a physical assessment, prevention interventions, and treatment of any conditions. (Adults with chronic diseases may need to be seen earlier than 60 days.)
  • Within 72 hours of transition, a team member with knowledge of the patient's history and plan of care should contact the patient to review the care transition plan (including medication and possible medication side-effects) and address any questions or new concerns.
  • Teach Back and open-ended questions should be used to assess and ensure the patient and family understands and is able and willing to follow through on the plan of care, including attending follow-up appointments
 Source of recommendations:

News and Happenings:
 
IPF Surveys:
We look forward to hearing about new interventions you have implemented since those visits, getting updates on your quality improvement projects, sharing new resources with you, exploring how we can help you understand and use your readmission measure dry run report to improve your care transition processes, et cetera.
 
Personalized Appointments:
Melanie will be contacting everyone soon, to set up a time to discuss the progress and/ or challenges experienced since the onsite visits last Spring. We look forward to hearing about new interventions you have implemented since those visits, getting updates on your quality improvement projects, sharing new resources with you, exploring how we can help you understand and use your readmission measure dry run report to improve your care transition processes, et cetera.

Upcoming Important Dates:
 
IPF Collaborative Call
Addressing Your Behavioral Health Patients' Physical Health Needs 
Thursday, April 26, 2018
1:00-1:45 pm
800-747-5150
Access Code: 5273638
This material was prepared by GMCF for Alliant Quality, the Medicare Quality Improvement Organization for Georgia and North Carolina, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
Publication No. 11SOW-GMCFQIN-G1-18-22