Blue Care Network Best Practices
Follow-up after hospitalization for mental illness
Family-centered focus and coordinated mental health care can help reduce hospital readmissions
Half of first-time psychiatric patients are readmitted to the hospital within two years of hospitalization. But proper follow-up treatment can increase quality of life for patients and reduce readmissions, according to the Agency for Healthcare Research and Quality.
Forest View Hospital in Grand Rapids aims to reduce hospital readmissions by coordinating outpatient care with mental health specialists and using a family-centered approach to the discharge process.
Kristin Mecklenburg, director of clinical services, explains that discharge planning begins when a patient arrives for an inpatient stay. “Our multi-disciplinary assessments are incorporated into the treatment plan,” she says. “We look at what we need to do to help the individual discharge safely and we work closely with patients and their families.” Regular chart reviews are an important part of the process to assure that clinicians make the appointment for follow-up visits within the required timelines.
The hospital’s medical director strongly encourages the family-centered approach because it reduces readmissions and helps patients resume their normal lives. “We make sure a family member or support person is educated about the discharge plan and how it helps the patient with treatment and recovery,” says Mecklenburg.
The approach is different for adolescent and adult patients. “The adolescent treatment program is more intensive because kids are actively involved with families,” offers Mecklenburg. “Multiple members of the treatment team have contact with parents or guardians.” For longer stays of 10 days, two or three family meetings may occur. For shorter stays, it might be one meeting. The goal is to educate patients and their support people about how to prevent the set of circumstances that led to the initial hospitalization.
“For our adult patients, we encourage family and support person involvement to provide education about why the patient needs follow-up,” says Mecklenburg. “It has a huge impact on their success.”
Hospital clinicians and case managers also work on crisis planning with the patient and family. They discuss the circumstances that brought the patient to the hospital and how to notice symptoms sooner and intervene before a hospital stay is necessary. “Our whole goal is to keep patients safe and prevent readmission,” says Mecklenburg.
Coordination with mental health providers
The hospital staff realizes the importance of working with community mental health providers to coordinate care. Clinical staff arranges aftercare plans and works with patients to match them with the appropriate mental health providers for follow-up care.
“We have a unique relationship with providers in the community,” says Mecklenburg. “We maintain regular outreach to them to make sure they’re happy with how things are going with patients. It’s that connection that allows us to feel confident in who we send our patients to. And it seems successful for most of our patients.”
The hospital coordinates care by sharing treatment plans and aftercare recommendations with mental health providers. “We work with the provider more intensely if the patient has already been seeing a mental health specialist before they were hospitalized,” says Mecklenburg. That includes providing 24 to 48 hour notice after admission to get input into treatment planning. “We also give them updated information throughout the patient stay,” says Mecklenburg. All patients’ records are faxed to providers so they have a record of the inpatient treatment and recommendations for follow-up care.
The hospital clinical team advises follow-up based on the individual patient’s needs. “We may have patients that really need follow-up in a day or two and we work to make the happen,” says Mecklenburg.
The same is true for psychiatry patients. “If they have complicated medication changes or issues with side effects, we may recommend follow-up in two weeks instead of the standard 30 days,” says Mecklenburg.
While the hospital does not measure outcomes of patients after they leave inpatient care, Mecklenburg says their combined patient-centered approach and coordination with providers helps ensure that most patients show up for their follow-up appointment.