Transition of Care Communication from the perspective of the outpatient clinic

Nystrom & Associates, Ltd.  Minnesota Based Mental Health Clinic with eight Minnesota locations and two Washington state locations.  Over 40,000 unique patient visits per year.  Patient population breakdown:  50% State / Federal Funded (Medicaid / Medicare)  Large commercial payer mix (Blue Cross Blue Shield, Medica, Preferred One, Etc)  Small cash pay population  Collaborative partnerships with many MN, WA, and National Organizations:  Nexus (Mille Lacs Academy, Gerard Academy)  Prairie Care  Health Partners  Medica  Multicare Associates (Fridley, Roseville, and Blaine Medical Centers)

RARE – The Five Key Areas  Patient / Family Engagement and Activation  Medication Management  Comprehensive Transition Planning  Care Transition Support  Transition Communications

Patient / Family Engagement and Activation  Systemic communication is important from the start!  The value of the referring entity in getting Releases of Information.  Family System involvement expectations from point of referral on.  This is an active discussion and dialogue!

Medication Management  The importance of accuracy.  Dossing expectations and communication.  Existing medications  Cross Clinic / Provider illness management.  Additional resources – Family, Friends, Case Workers, Group Homes, Etc.

Comprehensive Transition Planning  Clear plan of services  What follow up, when, where, goals?  Communication of documentation and information from referent  Set up release of information and communication expectations with patient at this time.

Care Transition Support  Timelines for care – clear expectations on urgency (NCQA, Joint Commission, Patient Need)  Care needs, medication management, community services, psychotherapy, chemical dependency, etc.  The key to a good referral  Patient buy in, informed consent, clear communication and expectations

Transition Communication - The Culmination of the 5 Key Areas  Back and forth communication expectations.  Needs of referent, needs of the clinic, needs of the patient  Release of information on both sides.

 Independent control – what are we able to take ownership of vs. what do we need to depend on other for.  Clear expectations on all areas from the start.

Collaborative Partnerships and Care Coordination  Value of formalizing collaborative partnerships  Use of a small handful of providers or one provider vs. many  Communication expectations – what to bring to the table

all Time makes all things fuzzy  Over time memory fades.  Importance of writing it down.  Referral guidelines  Memorandum of Understanding  Contracts  Periodic review and check in  If it doesn’t work, FIX IT!

 Clear expectations from day 1  Who is involved?  How do they communicate?  When it breaks, who is going to fix it?  Did you write it down?

When good intentions fail  The “set it and forget it” mentality  Assumptions hurt patients care  Failure is an opportunity – Do not overlook it!