Improving Follow-Up Care Within Seven Days of Discharge from Psychiatric Inpatient Facility
This session will include a brief overview of Boston Medical Center Health System, the workflows developed, and the clinical guidelines established to outreach and engage patients discharged from an inpatient behavioral health facility. Additionally, we will discuss successes and challenges of the program, as well as provide data demonstrating the program's efficacy.
Tool: Playbook for Follow-Up After Hospitalization for Mental Illness (FUH) Engagement
Problem: Gaps in timely Follow-Up After Hospitalization for Mental Illness (FUH) care (within 7 days of discharge)
Tool Selection: Lays out road map and strategies for how to be compliant with this important quality measure, detail strategies to engage patients for one-time clinical assessment within 7 days of inpatient psych discharge, applicable in a variety of settings
Usage: Used population health vendor Acadia to identify gaps in care for FUH based on measure specifications, used roadmap to generate daily outreach list, used best practices for patient engagement to reach patient and complete telephonic visit
Results: Leverages a licensed BH clinician within a population health team to offer clinical assessment and care coordination via telehealth to recently discharged patients. The clinician uses various resources and clinical techniques to engage patients, which has resulted in 10% overall improvement for Medicaid attributed members in Boston-area accountable care organizations.
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