Enhancing Mental Health Care Transitions: A Recovery-Based Model

Mental Health Care Navigators and Inpatient Psychiatry.

Christina Schwartz, BA Psychology, MHP, Mental Health NavigatorHeather Sievers, RN, MSN, MA Counseling Psychology, PI Advisor

Background Mental Health Crisis: Patient acuities are worsening and inpatient and

outpatient services are stretched thin. Between 2005-2010, over 50% of Minnesota’s inpatient mental health beds were closed. Lack of sufficient inpatient and outpatient mental health services are resulting in an influx of patients coming to the Emergency Departments to receive Mental Health care.

Received a Blue Cross Blue Shield grant to pilot an Enhanced Care Transitions Project at Abbott Northwestern Hospital in partnership with the Minnesota Community Healthcare Network (MCHN).

MCHN includes five outpatient Mental Health Agencies that together provide an integrated healthcare approach and comprehensive treatment for individuals living with serious and persistent mental illness and other complex conditions (including chemical dependency, chronic health conditions, and socioeconomic challenges): Guild Incorporated, Mental Health Resources, Resource Inc., Canvas Health, and Touchstone Mental Health.

Aim The aim of this project is to increase access to community supports

for ANW MH inpatients by developing a collaborative discharge and transition pilot with MCHN starting April 11, 2016 through the remainder of 2016.

Opportunities to enhance mental health recovery:1. Develop mental health interventions that enhance chances of successful

recovery in the outpatient setting and subsequently reduce readmissions. 2. Improve access to community Mental Health resources while a patient is

still hospitalized.3. Create patient-centered recovery model that promotes early patient and

family engagement in discharge planning. 4. Improve patient advocacy in treatment and demonstrate improvements in

patient experience. 5. Improve communication between inpatient and outpatient resources to

assure best care transitions and follow-up.

New Roles hired for Pilot Mental Health Navigator (started April 2016):

A MH professional who partners directly with the patient and care team to establish essential outpatient services, enhance discharge planning, support patient-centered recovery initiatives and conduct routine outpatient follow-up with MCHN contacts and patients.

Peer Support Specialist (started July 2016): A person with a mental health diagnosis who has been in recovery for a

minimum of 1 year and has taken PSS certification. Primary role responsibilities are to provide peer support, develop trusting

relationships, act as the patient advocate, participate or run recovery groups, engage patients more deeply in discharge planning, and provide outpatient follow-up as needed.

ANW-MCHN Pilot Workflow

ANW-MCHN Workflow continued…

Pilot Outcomes: April 11-Oct 11, 2016

Outcomes continued… Patient-Centered Recovery Interventions:

Readmission Results: Details: • 1 readmit due to medication

side effects• 1 decompensated at home and

required higher level of care• 1 sent to crisis bed but

behavior scared staff• 1 violated revocation of

provisional discharge

*Note: 29 of 92 pilot patients were homeless

Challenges: Private insurance: Patient’s aren’t eligible for case management services Only 1 MH navigator and 1 PSS covering all adult units and providing

outpatient services Original plan to have 3 Transitional Meetings: Goal Setting, Discharge

Planning and Day of Discharge with care team but unable to accommodate as program grows

Program has not spread to child/adolescent areas yet (most agencies are adult-focused)

Lack of adequate housing resources: 8 year delay in housing services in MN; get sent to crisis housing or shelter; Homeless Assessment required first, but only occurs after 14 stays at a homeless shelter. (Note: If a patient goes to a chemical dependency treatment facility, that counts as housing and drops their severity on the waiting list)

Hard to show full impact of our work only after 7 months. Need more time.

Overview of Program Successes: Why it works

“Individuals living with serious mental illness are often difficult to engage in ongoing treatment, with high dropout rates. Poor engagement may lead to worse clinical outcomes, with symptom relapse and rehospitalization.” (Dixon, Holoshitz, and Nossel, 2016).

Patient Engagement is the key to successful outcomes: Our program emphasizes the following elements of care:

1. Trusting Relationships: Consistency and continuity of care; strong inpatient and outpatient support systems, demonstrations of caring and commitment

2. Recovery-focused: Reestablish hope and empowerment of the individual to reach recovery and life success; emphasis on strengths, clear goals

3. Patient-Centered: Early engagement and autonomy; respect for an individual’s personal goals and wishes

Why our program is working: Our Program Interventions are geared at Patient

Engagement. New Roles and Relationships:

1. Peer Support Specialist: Patient advocacy, trusting relationship, hope for recovery, crisis intervention, friendship and peer engagement; inpatient and outpatient support; changing unit culture via a patient-centered recovery model, milieu management

2. Mental Health Navigator: bridge between inpatient and outpatient recovery; essential to streamlining transitions into the community; able to see patient in ED to reduce readmissions; inpatient and outpatient support; able to track patients in outpatient environment to help Allina understand patient outcomes

3. MCHN Agencies: a network of highly integrated, patient-centered organizations that also believe in the recovery model, onsite visits and care established prior to discharge, early follow-up post-discharge, hands-on care in the “real world”, diverse outpatient treatment opportunities; attend follow-up appointments with patients as needed

Why our program is working, cont…

Improved Communication and streamlined Transition of Care: 1. Onsite Visits or Conference Calls2. Coordination of Care: Able to work more directly with outpatient resources

that better understand the system and can support us in setting up the best outpatient services based on the patient’s needs.

3. Open exchange of Communication: Community Hub, MCHN ROI lasts 5 years; transmission of records; Navigator able to assist with medication or care challenges after discharge

4. Close-the-Loop Calls (includes patient when possible)Other Tools: 5. Recovery Plan: Goal setting and personal engagement in decision-making;

understanding support systems and plans for recovery and crisis intervention after discharge

6. Community Outreach Plan: Maintains continuity of care; easy method for contacting outpatient providers; supports work of social workers in early discharge planning for subsequent admissions. If patient readmitted or ED visit, able to notify agency contact immediately to help intervene early

7. Patient Experience Interviews (prior to and after discharge)8. Data Tracking: Flowsheet, Google Docs

Patient Experience “I feel confident that I will not have to come back to the hospital because I

will have more structure at home.” “This was a much more positive experience than my last hospitalizations,

thank you so much.” “I feel a lot more confident after working with you [Mental Health Navigator]

and getting hooked up with my new agency (MHR).” “Treatment was very individualized, everyone took time to help meet my

needs.” “Very positive experience, optimistic about resources, best hospitalization

I’ve ever had.” “Loved the groups and learning about new coping skills, and loved creating

my recovery plan” “Worked with Christina on triggers and coping skills. It feels like I got the

help I needed, and I feel good this time about going home” “This went so much better than last time and I feel confident going home.”

REFERENCES Dixon, L.B., Holoshitz, Y., and Nossel, I. (2016, February). Treatment

engagement of individuals experiencing mental illness: Review and update. World Psychiatry, 15(1): 13-20. doi: 10.1002/wps.20306.

Kreyenbuhl, J., Nossel, I.R., Dixon, L.B. (2009). Disengagement from mental health treatment among individuals with schizophrenia and strategies for facilitating connections to care: A review of the literature. Schizophrenia Bulletin,35:696‐703. doi: 10.1093/schbull/sbp046 

Le Boutillier, C., Leamy, M., Bird, V.J., et al. (2011). What does recovery mean in practice? A qualitative analysis of international recovery‐oriented practice guidance. Psychiatry Services, 62:1470‐1476. doi: 10.1176/appi.ps.001312011

Slade, M., Amering, M., Farkas, M. et al. (2014). Uses and abuses of recovery: Implementing recovery‐oriented practices in mental health systems. World Psychiatry, 3:12‐20. doi: 10.1002/wps.20084