A Health Home’s Role in Follow-up After Hospitalizations for Mental Illness

A 2014 statistical brief presented by AHRQ found mood disorders and schizophrenia were the top two reasons for hospital admissions among Medicaid’s highest utilizers. One large study found a rate of 37.5 percent for hospital readmissions and ED revisits within one year of hospital index admissions. While further research is required, the current literature has shown follow-up with an outpatient provider as an effective intervention to lower the risk of readmission. In 2015, only 65 percent of New York State Medicaid enrollees with an inpatient admission for treatment of a mental illness attended a follow-up appointment within 7 days of discharge. Thus, there continues to be a concerted effort, especially by Medicaid managed care plans and inpatient facilities, to ensure individuals have access to and are attending outpatient services after discharge. Much improvement is needed, though, and Health Homes can play a critical role in driving this improvement.

One model for predicting the receipt of aftercare services and recidivism proposes that engagement in post-hospitalization outpatient care is a function of:

  1. “Client vulnerability”: low socioeconomic status, co-occurring substance use disorders, previous hospitalizations, etc.
  2. “Community support”: housing stability, family involvement, etcetera
  3. “System responsiveness”: outpatient appointment access

While an ultimate goal of Health Home care coordination is to decrease member vulnerability, care managers can immediately assist members in increasing the utilization of community support and ensuring system responsiveness after hospitalizations. Many hospitals and managed care plans employ social workers to assist individuals in attending post-discharge appointments, but they are mainly limited to telephonic contact whereas Health Home care managers fill the void by helping the members face-to-face in their communities.

Hudson Valley Care (HVC) has been working closely with managed care plans, hospitals, care management agencies, and community-based providers to create more efficient flows of information between parties to best position Health Home members for successful outcomes after hospitalizations. This includes timely alerts of member hospitalizations, communication of discharge plans, and other pertinent information. While sometimes a seemingly arduous process, HVC has already made clear progress and is excited to further demonstrate measurable improvements in not only readmission rates for its members, but also in the long-term stability and overall health of its members.



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