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Monitoring Follow Up Rates

Community Care monitors follow up rates for members discharged from behavioral health hospitalizations.  Initiation of outpatient treatment shortly after hospital discharge has been shown to reduce readmission rates.  In each of our counties we monitor the rate of members discharged from an inpatient mental health hospitalization who receive an outpatient appointment within seven and 30 days of discharge.  The expectation is that all members discharged from a mental health inpatient stay will have an outpatient appointment within seven days.  This measure includes members with all diagnoses. 

We also monitor the rate of members who have an appointment with a prescribing clinician within 30 days of discharge from a mental health inpatient admission.  This measure includes members with all diagnoses.  The expectation is that members see a prescribing clinician within 14 days of discharge or sooner if the member has medication concerns. 

Community Care monitors the rate of members with follow up within seven days of discharge from non-hospital detoxification, rehabilitation, and halfway house in all of our counties as well.  The expectation is that members will receive treatment within seven days after discharge from these levels of care. 

Given that timely follow up can contribute to improved mental health status and reduce readmission rates, Community Care has implemented a number of interventions to improve follow up rates across our counties.  Outreach to members discharged from acute levels of care continues, as does follow up with providers to ensure the member has kept their appointment.  As part of Outreach, member identified barriers to aftercare are tracked.  Our Enhanced Outreach program utilizes active problem solving techniques.  A High Risk Care Management Team has been developed to facilitate discharge planning and transition to the next level of care.  Provider Benchmarking reports are sent annually to high volume inpatient providers in all of our counties to inform them of their rates of follow up care in comparison to individual providers, as well as the network average.  Corrective action is requested if the rates are below standards.  Additionally, record reviews are completed to determine rates at which inpatient providers educate members about the importance of follow up care. 

Some county specific interventions may include: Acute Case Management (ACM), Mobile Medication and the enhanced outpatient program.  ACM involves ICMs attempting to engage members who have not had success with traditional follow up services.  This service begins while the member is hospitalized and for 45 days after discharge.  Mobile Medication is a service where a practitioner will travel to a member’s home to ensure that they are taking their medication.  The enhanced outpatient program pays an increased rate to providers who either see a member while on an inpatient mental health or rehabilitation unit or see them within seven and 30 days of discharge.  This program also pays psychiatrists an enhanced rate for seeing a member within 14 and 30 days post discharge. 

Community Care will continue to monitor these rates ongoing and develop additional interventions as necessary to improve the rates. 

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