Monitoring Follow-Up Rates

Community Care monitors follow-up rates for members discharged from behavioral health hospitalizations who receive an outpatient appointment within seven and 30 days. Appropriate and timely follow-up care can result in sustained medication adherence and appropriate monitoring of symptoms as well as help maintain motivation for treatment and self-care among members at risk for relapse. The expectations are that all members discharged from a mental health inpatient stay will have an outpatient appointment within seven days and/or see a prescribing clinician within 14 days of discharge if they have a medication concern. These measures include members with all diagnoses.

Community Care also assesses the rate of members with follow-up appointments within seven days of discharge from withdrawal management treatment in all of our counties. The expectation is members will receive treatment within seven days after discharge from these levels of care.

Given the benefits of timely follow-up, Community Care encourages providers to accommodate a member’s individual needs and preferences related to race, ethnicity, age, and gender. Additionally, Community Care has implemented a number of interventions to improve follow-up rates across our counties, including but not limited to:

  • Community Care performs aftercare outreach to members discharged from acute levels of care and calls members to remind them of post-discharge appointments.
  • Community Care’s care managers may meet with members at an inpatient unit to identify barriers in attending follow-up appointments, address concerns, and facilitate discharge planning. This intervention was recently adjusted to now include children as well as other priority members, for example, members who may have readmitted over the standard 30-day readmission timeframe.
  • Provider Benchmarking reports are sent on a triennial cycle to all high volume inpatient providers in our counties to inform them of their rates of follow-up care in comparison to other providers as well as the network average. Quality improvement plans may be requested if the rates are below standards.
  • Community Care completes coordinated record review audits of mental health inpatient hospitals. These audits focus on keys factors necessary for successful discharge planning, such as scheduling of follow-up appointments, completion of medication reconciliation, and inclusion of family members.
  • Centers of Excellence (COEs) were launched in 2016 to expand access to counseling as well as other treatments such as Methadone Assisted Treatment (MAT), buprenorphine, or naltrexone. Additionally, Community Care implemented a process requiring providers to educate members on MAT as well as assess and identify members at risk for overdose.
  • Community Care implemented a value-based payment model in collaboration with providers and primary contractors. This project was initiated in January 2017 with ongoing growth and development throughout 2018 and 2019. A provider participating in this project may earn up to a 5% rate enhancement for meeting identified follow-up goals.
  • In-plan services continue to expand to increase the range of aftercare options available to members. These services may include mobile mental health services, certified peer specialists, mobile medication, Assertive Community Treatment (ACT) teams, psych rehab, school-based partial, blended service coordinators, and telehealth programs. The continuum of crisis services has been expanding to include walk-in and residential services.

Community Care will continue to monitor follow-up rates and develop additional interventions as necessary to improve these rates.