Coordinating Follow-up Care after Psychiatric Admissions

When members are admitted to the hospital for mental health needs, HealthPartners Behavioral Health is notified by the admitting hospital of the admission. A HealthPartners Case Manager will then follow-up with the hospital, the Member, and/or other collaterals or providers to support improved continuity of care between inpatient and outpatient behavioral health care.

Expected Outcomes:

Follow-up appointment with a mental health provider within 7 days of discharge

Increased/Ongoing follow-up care after hospitalization

Reduced readmissions and ER visits

Value Added by HP BHCM:

Clinical experience with evaluating reasons for the psychiatric admission, gaps in/barriers to care, and behavioral health needs.

Collaboration between Members, hospital teams, and collateral providers to coordinate post-discharge care by navigating and bringing together health plan and community resources. This may include, but is not limited to:

Primary care providers

Specialty care providers

Mental and chemical health treatment programs

HealthPartners Case Management and Disease Management programs

Facilitation of opportunities for SNBC delegates to communicate/connect with Members.

Collaboration between HP and SNBC Delegates:

Upon notification of an inpatient psychiatric admission, HealthPartners Case Managers will be contacting the SNBC delegate with the expectation that collaboration will occur regarding the following:

Collaborating with inpatient hospital staff about:

Reason for Admit

Gaps in Care/Clinical Needs of the Mbr

Education regarding need for a 7 day appointment

Available/Needed Providers and Resources and encourage contact with them

Interventions Tried

Coordinating a follow-up mental health appointment within 7 days of discharge, or as soon after discharge as possible.

Appointments must be at an Outpatient Mental Health clinic, Intensive Outpatient Program, or Partial Hospitalization Program and with a Mental Health Professional

Appointments cannot be with ARMHS, TCM, Primary Care, Psych Testing, or Group Home

Alert outpatient providers of the Member’s admission and assist with scheduling follow-up appointments.

Scripting suggestions for when contacting inpatient hospital staff to begin coordinating discharge planning:

I am a SNBC Care Coordinator with ________, contracted by HealthPartners, calling regarding (patient). My role is to assist in coordinating follow-up care for the patient after discharge. We’d like to see that the first follow-up appointment scheduled is with a mental health provider (therapist or psychiatrist) within 7 days of discharge, and we would like a copy of the discharge instructions.

I’ve already contacted the patient’s therapist and/or psychiatrist and he/she is willing to accommodate this time frame.

-OR-

This patient doesn’t appear to be established with any mental health providers according to the information we have. I can help with finding a new provider for him/her.

I plan to remain in contact with you as we coordinate the follow-up appointment and other discharge plans for this patient. Please call me when you know the discharge date and we can discuss the next steps and other needs the Member may have.