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Service Delivery Innovation Profile

Health Plan and Psychiatric Hospitals Reduce Readmissions by Reviewing Data and Developing Strategies to Improve Postdischarge Care


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Snapshot

Summary

Amerigroup Florida, a health plan, works collaboratively with seven psychiatric hospitals to improve patients' transitions to outpatient care, with the goal of reducing readmissions. The plan's behavioral health manager meets quarterly with hospital leaders to review data on admissions and length of stay, discuss select cases of readmitted patients to determine how patient care could have been managed differently, and identify strategies to improve quality and reduce the risk of readmissions going forward. Strategies focus primarily on steps that can be taken in the inpatient setting to facilitate the provision of appropriate treatment and support services after discharge. The program significantly reduced overall readmission rates at participating hospitals. Patients involved in specific quality improvement initiatives that came out of the program also experienced significantly fewer readmissions, along with associated declines in inpatient days and costs.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of overall readmission rates in participating hospitals, along with similar comparisons of readmissions, inpatient days, and cost savings related to three specific initiatives that came out of the program.
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Developing Organizations

Amerigroup
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Date First Implemented

2009
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Patient Population

Vulnerable Populations > Mentally illend pp

Problem Addressed

Many hospitalized psychiatric patients end up being readmitted after discharge. Some of these readmissions stem from inadequate support and monitoring in the outpatient setting.
  • Frequent readmissions: Up to half of all patients in psychiatric hospitals end up being readmitted within 1 year of discharge.1 One study found that 37 percent of mentally ill patients discharged from a psychiatric hospital required readmission within 1 year, compared with 27.3 percent of the general patient population.2 Before implementation of this program, 30-day readmission rates averaged roughly 18 percent at the Florida psychiatric hospitals that contract with Amerigroup health plan.
  • Driven by inadequate discharge planning and postdischarge support: Several factors drive these high readmission rates, including inadequate discharge planning, medication nonadherence, lack of systems to ensure outpatient behavioral health followup, impairment to patients' ability to care for themselves, lack of access to community services and family support, and substance abuse.2

What They Did

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Description of the Innovative Activity

Amerigroup's behavioral health manager meets quarterly with leaders at seven psychiatric hospitals to review data on admissions and length of stay, discuss select cases of readmitted patients to determine how their care could have been managed differently, and identify strategies to improve quality and reduce the risk of readmissions going forward. Strategies focus primarily on steps that can be taken in the inpatient setting to facilitate the provision of appropriate treatment and support services after discharge. Key program elements include the following:
  • Quarterly data sharing: Each quarter, the health plan's behavioral health manager meets with hospital representatives (generally the behavioral health medical director, the director of utilization management/discharge planning, clinical staff, and finance/operations personnel) to review data on recent performance. The manager presents quarterly data for the past 3 years in table and graph form to illustrate trends in admissions, readmissions, and average length of stay.
  • Case review: The behavioral health manager provides a list of all patients readmitted within 30 days of hospitalization during the prior quarter. The group reviews four or five cases, identifying and discussing factors that might have led to the readmission, such as premature discharge, lack of a timely followup visit with a behavioral health practitioner, medication nonadherence, or substance abuse.
  • Joint strategies to improve quality, reduce readmissions: Based on the problems identified during case reviews, the group develops joint health plan–hospital initiatives to improve care processes, with the goal of preventing readmissions. Such activities might include arranging postdischarge followup visits and/or coordinating referrals to outpatient behavioral health providers, case management programs, group therapy, or support groups. Sample initiatives include the following:
    • Provider education about medication alternatives: The health plan educates providers about the use of longer-acting antipsychotic injectable medications in patients who may not adhere to daily oral regimens. If necessary, the health plan will arrange for a nurse to visit the patient's home to administer the injection.
    • Linkage to outpatient services: Many strategies involve inhospital initiatives to help patients access appropriate outpatient services after discharge; examples include:
      • Facilitated followup appointments: Through its "extensivist program," the health plan arranges for behavioral health practitioners to visit inpatients on the day of discharge to arrange outpatient followup appointments and support services.
      • Outpatient case management initiated during inpatient stay: Case managers participate in the health plan's daily "rounds" (offsite case review) of all psychiatric inpatients to determine if a patient would benefit from case management services after discharge. If so, the case manager either calls or visits the patient (while still in the hospital) to initiate such services.
      • Automatic, facilitated access to behavioral health services for children: Under Florida's Medicaid program, children and adolescents hospitalized for behavioral health services qualify for coverage of "therapeutic behavioral onsite services," provided on an outpatient basis. Examples of these services include assessment of mental health and substance abuse problems, outpatient therapy, skill building, support groups, and goal-setting. Amerigroup authorizes these services while the patient is hospitalized and presents the hospital with a list of qualified providers. Hospital staff then work with the patient's parents before discharge to schedule an appointment.
    • Facility-specific initiatives: Quarterly meeting participants determine how hospital-specific processes could be improved to enhance quality and service. For example, meeting participants at one hospital realized that readmitted patients often were assigned to a different physician during each inpatient stay. The hospital created a new process in which patient registration staff assigned the physician who previously provided care to these patients.
  • Onsite inpatient reviewer: Information provided in February 2012 indicates that the program has now placed an onsite inpatient reviewer at the second-largest-volume facility, which has allowed for stronger discharge planning. In 2012, this clinician will also assume responsibility for case management for members at this facility, allowing for continuity of care from the inpatient to the outpatient setting.

Context of the Innovation

Amerigroup, a health plan headquartered in Hampton Roads, VA, provides services to more than 2 million individuals enrolled in publicly funded health care programs in 12 states. Amerigroup Florida's service population includes 260,000 members covered by Medicare, Medicaid, the Children's Health Insurance Program, and the state's Healthy Kids program. In 2007, new leadership at Amerigroup Florida began a careful examination of utilization data, which led to the identification of above-average 30-day readmission rates, lengths of stay, and care costs in 8 of the 47 psychiatric hospitals participating in its Florida network. Based on their analysis, Amerigroup Florida leaders decided to provide greater support to these facilities, with the goal of preventing unnecessary readmissions.

Did It Work?

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Results

The program significantly reduced overall readmission rates at participating hospitals. Patients involved in specific quality improvement initiatives that came out of the program also experienced significantly fewer readmissions, along with associated declines in inpatient days and costs.
  • Fewer readmissions: In 2008 (before program implementation), the overall readmission rate among participating hospitals was 17.7 percent. Updated data provided in February 2012 indicates that five participating hospitals decreased readmissions from 12.62 percent in 2010 to 10.87 percent in 2011, while another two decreased readmissions from 12.79 percent in 2010 to 10.36 percent in 2011. Specific initiatives also led to reductions in readmissions, as outlined below:
    • Switching medications: Patients switched from oral to long-acting injectable medications experienced a 38-percent decline in readmissions over 27 months (July 2008 to September 2010). Information provided in February 2012 indicates that continued use of the long-acting antipsychotic medications has been stable.
    • Behavioral therapy for children: Children and adolescents receiving therapeutic behavioral onsite services experienced a 39-percent reduction in readmissions over 22 months (July 2008 to April 2010).
    • Day-of-discharge visit: Patients receiving a day-of-discharge visit from the extensivist experienced a 21-percent reduction in readmissions over a 17-month period (May 2009 to September 2010).
    • Onsite inpatient reviewer: Information provided in February 2012 indicates that the addition of the onsite inpatient reviewer has resulted in a 2.75-percent reduction in readmissions and a 17-percent reduction in inpatient days after 1 year. 
  • Fewer inpatient days: The initiatives outlined above led to associated reductions in inpatient days, with the switch to long-acting medications generating a 51-percent decline, the provision of behavioral therapy for children generating a 27-percent drop, and the day-of-discharge visit leading to a 13-percent decline (all over the same time periods outlined above).
  • Lower costs: The program-specific reductions in readmissions and inpatient days have translated into substantial cost savings, with the switch to long-acting medications leading to a 38-percent decline in costs (worth more than $372,000), the provision of behavioral therapy for children generating a 24-percent drop (more than $100,000), and the day-of-discharge visits reducing costs by 14 percent (more than $66,000).

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of overall readmission rates in participating hospitals, along with similar comparisons of readmissions, inpatient days, and cost savings related to three specific initiatives that came out of the program.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Developing program description and participation agreement: Program developers—including the vice president of health care management services, the behavioral health manager, a member of Amerigroup Florida's legal team, the manager of inpatient review, and the director of provider relations—developed a three-page document outlining the impetus for the program and the expectations for Amerigroup and participating hospitals and providers. Based on this document, the team developed a one-page (nonlegal) agreement for hospital representatives to sign.
  • Meeting with provider relations team: Program developers met with Amerigroup Florida's provider relations team to describe the initiative and identify representatives to contact at each of the eight hospitals, which were selected for the program based on their high readmission and utilization rates.
  • Soliciting facility interest: Program developers called the facility representatives to introduce the initiative and solicit their interest in participating. All agreed to participate; the facility representatives then invited select providers and employees to attend an onsite outreach meeting hosted by Amerigroup Florida representatives.
  • Educating Amerigroup clinicians: Program developers met with behavioral health clinicians within Amerigroup Florida to describe the program.
  • Planned expansion: Program leaders are currently defining additional indicators (e.g., the percentage of 7- and 30-day followup appointments kept) that can be incorporated into the quarterly meetings, thus allowing participants to identify, discuss, and address additional barriers to patients receiving appropriate postdischarge care.

Resources Used and Skills Needed

  • Staffing: The behavioral health manager spends approximately one-third of her time on quarterly visits to the eight hospitals. Other staff incorporate program-related duties into their everyday responsibilities.
  • Costs: Program costs are minimal, consisting primarily of the time and expenses associated with the behavioral health manager's travel to the different hospitals each quarter.
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Funding Sources

Amerigroup
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Adoption Considerations

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Getting Started with This Innovation

  • Start small: Only implement the program in a few hospitals to ensure that it can be delivered thoroughly and effectively. Once this has been determined, consider expansion based on resource availability.
  • Ensure internal buy-in before meeting with hospitals: For example, if the plan's provider relations staff are hesitant about the initiative, their lack of support will be communicated to providers and thus undermine the initiative's potential.
  • Be flexible regarding meeting participation: Initially, the meetings might not include the right staff members or clinicians. Over time, however, meeting participation will change, eventually bringing in the right players.
  • Ensure ability to produce reliable data: Ensure that internal personnel can produce the data reports needed to guide the quarterly meetings. Without it, meetings will not be compelling, as anecdotal data alone cannot drive process improvement.

Sustaining This Innovation

  • Measure and share results to promote program expansion: Continually monitor and share data on the program's positive impact on quality and costs. In fact, the success to date has made Amerigroup Florida leaders consider funding an additional behavioral health manager so that the program can be expanded to all inpatient behavioral health facilities in its network.
  • Share best practices across hospitals: Because an initiative developed by one hospital may prove beneficial at others, the behavioral health manager should leverage all opportunities to share successful strategies across hospitals. This process helps hospitals gain more value from the quarterly meetings and their relationship with the health plan.
  • Act on provider feedback about health plan: During the quarterly meetings, the behavioral health manager may hear complaints or concerns about specific negative interactions with the health plan (e.g., a problem with customer service, difficulty getting a claim paid). The behavioral health manager should communicate this feedback to provider relations staff, who, in turn, should resolve the problem as soon as possible. This responsiveness ensures that hospitals and providers view the health plan as a true partner.
  • Continually refine and improve program: Consider how new services and data can further help hospitals improve utilization and quality.

More Information

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Contact the Innovator

Susan Bramer, MS, LCSW
Associate Vice President, Health Care Management Services, Behavioral Health
Amerigroup Florida
4200 West Cypress Street
Tampa, FL 33607
(813) 830-6938
E-mail: susan.bramer@amerigroup.com

Innovator Disclosures

Ms. Bramer has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

AHIP Center for Policy and Research. Innovations in Reducing Preventable Hospital Admissions, Readmissions, and Emergency Room Use. June 2010. pp. 22-3. Available at: http://www.ahip.org/uploadedFiles/Content/Departments/Policy_and_Research/Innovations_Report_Series
/Innovations-2010-Report.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)

Footnotes

1 Bridge JA, Barbe RP. Reducing hospital readmission in depression and schizophrenia: current evidence. Current Opinion in Psychiatry. 2004 Nov;17(6):505-11.
2 Madi N, Zhao H, Li JF. Hospital Readmissions for Patients with Mental Illness in Canada. Healthcare Quarterly. 2007;10(2):30-2.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: February 02, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 12, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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