Time to Transition to Better Transitions of Care

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Some $25 billion to $45 billion per year is lost on poor transitions of care, meaning a failure of the healthcare system to properly transfer a client from the care of one clinician in a certain setting to the care of another clinician in another setting. There are many reasons for this, but it most often happens due to lack of information sharing.

In the behavioral health community, where as many as 68 percent of adults with mental health conditions also have medical conditions, there is tremendous opportunity for cost savings – and more importantly, better client outcomes – if transitions of care are improved.

One place we would immediately see this is with hospital readmissions. A recent study indicated that behavioral health discharges ranked among the top five diagnostic categories for 30-day readmissions to the hospital.

Transitions_Of_Care_Cost_InfoGraphicDoing a better job reconciling medications, improving discharge planning, better organizing discharge summaries, helping clients schedule follow-up appointments, making a post-discharge phone call to determine the status of a client’s follow-up care, and providing supporting clinicians and physicians access to web-based discharge information are all ways that we can avoid faltering.

We’ve seen it work in Florida, where Suncoast Center, Inc., an outpatient behavioral mental health center, and Personal Enrichment through Mental Health (PEHMS), an inpatient psychiatric hospital, have been using CareConnect since December 2013 to share records and expedite referrals. The system allows PEHMS staff to directly schedule post-discharge appointments at Suncoast, thus removing the barriers to follow-up care. PEHMS nurses can also verify that the medications a client needs are available at Suncoast. When the client arrives, their health history, previous diagnosis and treatment information is readily available to the admitting staff, alleviating the painful step of retelling his or her complete story and situation yet another time unless it is necessary for other reasons.

Transitions of care, however, should not be considered solely between an acute care setting and a behavioral health outpatient environment. Transitions of care apply to any client handoff, including:

  • Acute care setting to a behavioral health care setting,
  • Acute care or behavioral health care setting to a patient’s home
  • A skilled nursing facility to another ambulatory setting
  • Correctional institution to a community behavioral health care setting

A key part of the care coordination model, a quality transition of care will improve patient safety, increase efficiency, eliminate redundant or unnecessary testing, better engage clients in their treatment, improve public health reporting and monitoring, and reduce healthcare costs.

Behavioral health care can take the first step at making this much needed “transition.” Look around your community and find partners – Be the catalyst to improve transitions of care for your clients.