Transitional case management
Increasing follow up after hospitalization
By Brandy Gadino, MA, Regional Director, Quality Management and Sharon Gollaher, RN, MBA, ACM-RN, CMCN, Director, Behavioral Health Services
Overview
Why is ambulatory follow up important?
In 2019, nearly one in five adults age 18 and older was diagnosed with a mental health disorder. Despite this number, those hospitalized with mental health disorders often do not receive adequate follow-up care.
Follow-up care after a psychiatric hospitalization can greatly improve patient outcomes, reduce the likelihood of rehospitalization, and decrease the cost of patients’ overall care.
After patients are discharged from an inpatient setting, ambulatory follow-up care is important. Connecting patients with a mental healthcare provider increases the chance of a successful transition from the hospital back into the community; the provider helps make sure patients continue to follow their treatment plan and take the correct medications. A case manager also removes any barriers that may prevent patients from following up with their provider.
The main goal of ambulatory follow up is to improve patient care, leading to a healthier, more positive, and more cost-effective outcome for the patient.
What is HEDIS®?
HEDIS® refers to the Healthcare Effectiveness Data and Information Set developed by the National Committee for Quality Assurance (NCQA). It is a set of performance measures used in the managed care industry and is part of the NCQA accreditation.
Following these standards is essential to Carelon in making sure members receive the best-quality care, which is achieved through collecting and analyzing data. The data documents the clinical care that each plan member receives from their providers through their health plans. The data is used to report on the overall care that plan members receive.
The reports are a major part of quality rating systems, which measure the performance of Centers for Medicare & Medicaid Services and of states offering Medicaid.
HEDIS® Measure: Follow-Up After Hospitalization for Mental Illness (FUH)
Evidence shows that those who receive follow-up care after experiencing a psychiatric hospitalization have lower readmittance to an inpatient facility. When patients receive more consistent care, their mental health outcomes improve, and they are more likely to return to less restrictive levels of care. FUH tracks the number of patients who see an outpatient mental health practitioner within seven (FUH-7) to 30 days (FUH-30) of discharge.
Data1
By Brandy Gadino, MA, Regional Director, Quality Management and Sharon Gollaher, RN, MBA, ACM-RN, CMCN, Director, Behavioral Health Services
23%
After two California health plans implemented TCM* as an intervention, the plans indicated an average FUH-7 rate of over
20%
The same health plans showed an average FUH-30 rate of over
7%
After using TCM as an intervention, 13 nationwide health plans showed an average FUH-7 rate of over
7%
The same health plans showed an average FUH-30 rate of over
* TCM = transitional case management
Barriers to follow up after hospitalization
Several barriers prevent patients from maintaining their follow-up care after hospitalization.
Facility barriers
- Lack of organized procedures in place for follow-up care
- Access issues, including unfamiliarity with finding and scheduling follow-up care
- Lack of knowledge on payer resources
- Not enough reimbursement
Member barriers
- Lack of social support
- Homelessness
- Transportation
- Affordability
- Stigma
- Perceived reduction in symptoms
- Noncompliance with medication
- Technology (unable to use telehealth)
Case manager barriers
- Unable to reach patient
- Lack of access to mental health providers
Transitional case management
According to the Centers for Medicare & Medicaid Services (CMS), patients can take advantage of covered services when transitioning back to a community setting, after hospitalization at qualifying facilities. TCM requirements include:
- Supporting the patient’s transition to a community setting.
- Healthcare providers accepting patient care at a post-facility discharge without a service gap.
- Healthcare providers taking responsibility for a patient’s care.
- Healthcare providers making complex decisions about patient care and next steps.
A patient’s TCM period begins on their inpatient discharge date and continues for the next 29 days. Their TCM services begin on the day of discharge from the following settings:
- Inpatient acute care hospital
- Inpatient psychiatric hospital
- Long-term care hospital
- Skilled nursing facility
- Inpatient rehabilitation facility
- Hospital outpatient observation
- Partial hospitalization
- Community mental health center
A patient must return to one of the following settings after they’ve been discharged from an inpatient facility:
- Home
- Nursing home
- Assisted living facility
TCM components
When a patient leaves an approved inpatient setting upon discharge, they must be provided the following TCM components over a period of 30 days:
- An interactive contact within two days of discharge, via phone, email, or in person.
- Virtual services as appropriate.
- Legally authorized physician and nonphysician practitioner (NPP) services.
- In-person TCM services, requiring the following codes:
- CPT Code 99495: any communication with the patient or caregiver within two business days of discharge; medical decision made within the service period; and in-person visit within 14 calendar days of discharge.
CPT Code 99496: any communication with the patient or caregiver within two business days of discharge; medical decision made within the service period, and in-person visit within seven calendar days of discharge.
TCM in the managed behavioral healthcare organization (MBHO) setting
When a patient leaves an inpatient facility after discharge, they will be reached by an MBHO case manager within the next day. The case manager will engage the patient in completing the TCM form.
The case manager will add the completed TCM form to the patient’s record along with the appropriate codes. The form will provide another source of data for the FUH HEDIS® measure.
Next steps
The TCM benefit has had a significant positive impact on FUH rates in California. As such, Carelon will explore similar opportunities in other markets.
Opportunities may include working with strategic partners to administer TCM services to post-discharge patients, as well as expanding intervention concepts overall.
1 Internal data, 2023.
