Mid-Valley Behavioral Care Network manages the mental health and alcohol and drug benefits for all Oregon Health Plan members in Marion and Polk Counties – a huge task.

THE PROBLEM

The provider organization’s behavioral care coordinators and provider network case managers, psychiatrists and therapists were struggling to effectively coordinate patient care, too.

“We had to call hospitals in the area looking for the right contact – sometimes the patient information wasn’t accurate,” said Lisa Parks, quality improvement coordinator at Mid-Valley Behavioral Care Network. “And we were constantly checking our fax trying to find any information about our patients after they were discharged from local emergency departments.”

This might seem like part of the job for clinics, but staff members were taking a massive amount of time away from the patients seeking behavioral health treatments within the provider network. Then when those patients were discharged, many providers had the same problem – no way of following up with their medical history until they showed back up for treatment or staff found out information from other providers.

In some cases, patients were being readmitted to the hospital because staff could not find them to give them the support they needed.

PROPOSAL

This is where Mid-Valley Behavioral Care Network turned to health IT vendor Collective Medical. A few years ago, Oregon decided to implement the Collective Medical platform statewide, and Mid-Valley quickly realized the platform was the solution it needed.

“The platform connects every member on a patient’s care team so they can collaborate on care plans and stay up to date on patient histories,” Parks said.

In Mid-Valley’s case, the behavioral care coordinators and provider network receive notifications from on-network hospitals when a patient has checked into the emergency department, allowing staff to reach out and schedule a follow-up appointment early on.

This system allows Mid-Valley to share patient data so staff doesn’t have to call around, dig through irrelevant information, or hope the patient follows discharge instructions. Not only has this increased the quality of patient care, it benefits other clinics and hospitals that are on-network because everyone is on the same page, Parks said.

MARKETPLACE

There is a variety of care coordination and communication systems on the health IT market today, with vendors including DocbookMD, Halo Communications, Imprivata, Klara, Lua, QliqSOFT, Spok, Telmediq, TigerConnect, Voalte and Vocera.

MEETING THE CHALLENGE

After implementing the Collective Platform, Mid-Valley behavioral care coordinators and provider network case managers can easily track patient data and new care histories in real time. With this software, staff run reports to identify high-utilizing patients – those that visited the emergency department three or more times in the past three months.

“Now that we know who and where these patients are, we have the ability to reach out and connect them with therapists or psychiatrists to prevent future readmissions,” Parks explained.

Mid-Valley also has been able to monitor and track follow-up rates and patient outcomes on a daily basis. Before, staff was just trying to piece it together.

“These patient insights are priceless when managing and training our staff, which leads to even better patient engagement and follow-up, so fewer patients are returning to the hospital after discharge,” Parks stated. “We’re ultimately saving the hospital money by reducing avoidable emergency department admissions and readmissions.”

"The platform connects every member on a patient’s care team so they can collaborate on care plans and stay up to date on patient histories."

Lisa Parks, Mid-Valley Behavioral Care Network

But most important, patient outcomes have improved because Mid-Valley has been able to quickly connect patients to the best resources to manage their health conditions, Parks added.

“Before, if emergency department staff didn’t know about a patient’s mental health condition, they might run unnecessary tests and keep the patient in the department,” she said. “Now we can quickly reach out and get the patient moved from the hospital to a behavioral center – it’s never been more seamless.”

RESULTS

Using the platform, Mid-Valley increased its patient follow-up rate within 7 days to 75.86 percent. The national average is only 18 percent within 30 days, according to the National Committee for Quality Assurance.

Higher follow-up rates mean fewer patients retiring to the hospital after discharge, meaning a reduction in avoidable emergency department admissions and readmission, ultimately saving the hospital money and other clinical staff resources as well.

“We are seeing a really big difference in being able to track using these reports,” Parks said. “It’s all helping us see where we’re really at in our coordination efforts and care.”

Follow-up is key in helping psychiatric patients get the help they need following any crisis situation. For example, one Mid-Valley provider had a child patient admit to the emergency department after attempting to commit suicide. The provider was able to use the platform to contact the child’s therapist and provide information about the incident the next day. Both the patient and family were able to begin the therapy when and where they needed it.

“This serious situation could have turned out a lot differently if the child wasn’t smoothly transitioned from hospital to therapist,” Parks said. “This coordination between clinics and hospital is so important for all patients struggling with mental health conditions. This cooperation ensures each patient gets the personalized care, medication and counseling resources they need.”

ADVICE FOR OTHERS

“If you are working with vulnerable patients, real-time alerts like these help you locate and support your patients,” Parks advised. “That engagement is so important. Something as simple as setting follow-up appointments with regular check-ins is invaluable.”

What makes this program work so well is community collaboration, she added.

“Everyone needs to be on board working together for the same goal: Helping our patients,” she said. “The health system is unnecessarily siloed when we should all be working together. It’s helpful to have results that back up why care collaboration is so important for both providers and our patients. By working together as one big medical neighborhood, we can make the biggest impact on individuals and our community.”

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com