Community Care Coordination and Engagement Project

Program Description

In 2015, McClendon Center took a bold new step and entered into a partnership with AmeriHealth Caritas DC, a Medicaid managed care provider, and launched the first of our engagement services, Patient Discharge Coordination (PDC). PDC ensures a seamless patient transition from (psychiatric) hospital care to discharge and continued psychiatric care by providing aggressive care coordination with the individual and external service providers. We then took the next step, expanding our services to include Behavioral Health Engagement Services (BHES) and Post Emergency Evaluation Services (PEES). This comprehensive approach 1) ensures patients in psychiatric hospital care re seamlessly transitioned back into the community and are connected to behavioral health services (PDC); 2) engages people in the community (many who are staying in shelters or are transient) who had previously been lost to treatment (BHES); 3) provides post-discharge assistance to members with behavioral health concerns and have recently received emergency treatment; and 4) targets those needing focused outreach services to reduce the rate of potentially preventable admissions.

Creativity

McClendon Center is a pioneer in innovation and, as far as we know, is the first DC mental health provider to partner with a Managed Care Organization (MCO). The Patient Discharge Coordination (PDC) ensures that patients in hospital psychiatric units experience a seamless transition back into the community, are connected to ongoing support and services, and receive medication education. (Behavioral Health Engagement Services (BHES) engages a “rover” (contract employee) to find people in our community who have been lost to treatment and help them reconnect to support services. And our Post Emergency Evaluation Services (PEES) provide assistance to individuals who have recently visited a hospital emergency department and have behavioral health concerns. Through these engagement programs, we are successfully re-connecting individuals to the behavioral health care they had lost, while reducing the incidents of re-hospitalization and ER admissions.

Leadership

Our Care Coordination and Engagement Project is a model that can be replicated by behavioral health and MCOs. Our model with the our relationship with AmeriHealth, which was fostered by Dennis Hobb, McClendon Center Executive Director. After the PDC partnership, contracted rates, and a team of care coordinators were established, implementation began immediately. The positive impact was quickly evident, and the program was expanded to include BHES and PEES. It also led to a creative partnership between AmeriHealth, McClendon Center, and Woodley House. Woodley House, which provides housing supports to people in DC with mental illness, is housing PDC clients post-discharge. To promote our model, McClendon Center and AmeriHealth Caritas DC) have, collectively and individually, presented our care coordination project at the 2017 National Council Conference, , the Maryland Behavioral Health Conference, the DC Hospital Association, and three webinars for the Centers for Medicare and Medicaid Services.

Sustainability

A crisis is building in mental health services, with demand rising faster than resources can handle, including the struggle to integrate primary and behavioral health management. As a result, uninsured or Medicaid users tend to use ERs for non-emergency concerns. Our Care Coordination and Engagement Project targets such individuals with behavioral health conditions, co-occurring disorders and other social comorbidities, and reduces the number of costly admissions and ER visits. MCOs thus have a vested interested in establishing similar partnerships with behavioral health providers. The success of our initial PDC program has led to similar contracts with Trusted Health Plan, and we are now exploring other ways to expand and partner with MCOs, hospitals, and Accountable Care Organizations. We believe that as long as MCOs have members who are hospitalized, use ER services, and have behavioral health needs, this program can be sustained and expand in new ways.

Replicability

McClendon Center is in the process of updating its PDC PowerPoint presentation (attached) that addresses need, implementation, challenges, and anticipated outcomes. The updated presentation will include our BHES and PEES services, and results that can be shared with interested institutions and behavioral health providers. Our model is based on establishing and using our relationships with MCOs, other providers, and psychiatric inpatient units. However, our model can be adapted for use by schools, jail systems, shelters — wherever there are at-risk individuals in need of behavioral health care coordination, and where such care coordination can mitigate financial burdens to MCOs and municipal agencies; and, at the same time, help support and sustain nonprofit and not-for-profit behavioral health care providers.

Results/Outcomes

During the past year, our dedicated Care Coordination staff served more than 3,600 DC men and women. Because of the intensive and rapid engagement period, our clinical staff are deeply knowledgeable of medical conditions, appropriate medications, and intensely involved with the planning for and continuation of post-discharge care, help with locating housing, and provide regular follow-up visits for at least 30 days. Specific results include: improved adherence to post-discharge Healthcare Effectiveness Data and Information Set (HEDIS) measures by more than 300%; reduced 30-day re-admissions from 14% to 8.4%; and minimized hospital stays, thereby freeing crisis beds for use by other patients needing skilled nursing care. Financially, with the rates we negotiated, we are able to hire highly qualified staff to deliver these services.