How to Create a Transitional Outpatient Program for Behavioral Health Inpatients

Case managers are a pivotal element of a new program designed to improve care for behavioral health patients up to three months after hospital discharge.

A collaboration in Rhode Island between a behavioral health hospital and a payer seeks to reduce hospital readmissions and improve quality of care.

Readmissions are a significant issue in hospitalizations for behavioral health conditions. A research article published by the Agency for Healthcare Research and Quality examined data from more than 840,000 hospital stays for mood disorders and more than 380,000 hospital stays for schizophrenia. The 30-day readmission rate for mood disorders was 9.0%, and the 30-day readmission rate for schizophrenia was 15.7%.

In December, Butler Hospital in Providence, Rhode Island, launched its pilot Transitional Outpatient Program for patients who have insurance coverage from Blue Cross & Blue Shield of Rhode Island.

"The program is targeted from one month to three months after hospital discharge—that is the time that problems are more likely to develop and people need extra support. What we offer is a collection of different services depending on the needs of the patient. Those services include case management, which is what we have teamed up with Blue Cross to provide. It is short-term case management for those initial months after hospital discharge. In addition, patients often benefit from getting additional counseling, therapy, and medication management," says Brandon Gaudiano, PhD, clinical director of the Transitional Outpatient Program.

Butler Hospital can provide outpatient services on a timely basis after hospital discharge if those services cannot be set up in the community, he says. "If patients need new healthcare providers or need to be seen sooner than they can be in the community, Butler Hospital has providers who can provide those services to make sure that the time between hospital discharge and being seen by a provider is shortened."

Many patients who have a behavioral health inpatient stays are at risk of rehospitalization, Gaudiano says. "With the types of diagnoses that patients are dealing with, such as substance use disorders, risk of relapse can be very high. There are also diagnoses such as mood disorders—bipolar disorder and severe depression—where patients need a lot of extra assistance and help. There are also patients with schizophrenia and other psychotic spectrum disorders who often are dealing with chronic conditions, where even if the acute episode is over there are still many things they need assistance with."

The Transitional Outpatient Program is designed to make sure that patients receive care after their hospital discharge, he says. "We want to make sure the treatment that patients get continues after they leave the hospital. Patients go from very intensive, 24-hour monitoring and support to typical outpatient treatment, which might be meeting once per week with a clinician."

With the new program, patients get support from a team of professionals who work together to monitor the patients' situations, help them to problem-solve, and identify if there are certain needs that are not being met that can be addressed with services, Gaudiano says.

"Our approach prevents things like nonadherence to treatment—we can make sure that we are supporting the patient, make sure that they can continue with their medication, and make sure that they can continue to get to their appointments. We can make sure that patients are being followed up, monitored, and reassessed for any kind of risk factors that might be developing. It is nonadherence problems and not being able to manage stressors effectively that trigger relapse and rehospitalization."

How the Transitional Outpatient Program was implemented

The most innovative element of the new program is case management, Gaudiano says.

"Adding in case management provides an extra level of support and care that otherwise is not typical of care when patients leave the hospital. We feel that if patients have short-term case management, that extra support that patients need in a limited time can help to reduce rehospitalizations. Often, patients need help with a variety of different issues that they are dealing with in the community. There might be several social determinants of health issues that a case manager can address and help the patient problem-solve. The case manager can help the patient access services for housing, financial issues, or other problems that they might be having," he says.

Two part-time case managers are the only new hires for the Transitional Outpatient Program, Gaudiano says. "We also have the outpatient therapists and prescribers, which include psychiatrists. They are basically devoting some of their time for this new program, but they were already employed at the hospital. So, this program does not require completely new staff because we can repurpose some staff or expand their duties to include this new program."

Therapy is individualized for the patients based on their mental health needs, he says. "Typically, it is a short-term model of care that identifies the patient's goals after hospital discharge. We want to make sure patients are supported in achieving those goals. Often, there is cognitive-behavioral treatment and short-term counseling that is provided. We also make sure our therapists provide safety planning to reduce suicide risk."

Medication management is another key element of the Transitional Outpatient Program, Gaudiano says. "Patients often have medication changes done when they are in the hospital. In seeing a provider after patients leave the hospital, sometimes there are further medication adjustments as their symptoms improve or as they adapt to the medications. So, a medication provider will assess that and adjust medications as needed to make sure that medications are continuing to work for the patient."

Measuring effectiveness of the program

Readmissions are the primary metric being used to gauge the effectiveness of the Transitional Outpatient Program, says Sarah Fleury, LICSW, manager of behavioral health at Blue Cross & Blue Shield of Rhode Island.

"The main quality metric that we are looking at is readmissions—we are hoping to lower 30-day readmissions for members who go through this program by 5%. If we can achieve a 5% reduction in readmissions—taking into account the costs of the case managers—we expect to have about $118,000 worth of net savings per year. That would be about 14 fewer readmissions per year," she says.

The Transitional Outpatient Program should be a good example of a behavioral health initiative that generates a return on investment and improved clinical outcomes, Fleury says. "The cost of the case managers, which is the component that we are adding, should ultimately result in a net savings from reduced readmissions. So, the program should generate a return on investment, and it ensures that our members have access to high quality care."