Follow-up Rates

Community Care monitors follow-up rates for members discharged from an Inpatient Mental Health Hospital (IPMH) and who receive an outpatient appointment within 7 and 30 days. Appropriate and timely follow-up care may 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 of relapse. The expectations are that all members discharged from an IPMH hospital will have a follow-up appointment within seven days.

Community Care also assesses the rate of members who attend follow-up appointments within seven days of discharge from withdrawal management and/or residential substance use disorder treatment across all contracts. The expectation is members will have a follow-up appointment for substance use disorders 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, language, age, and gender.

In Quarter 2 2026, Community Care completed a Root Cause Analysis (RCA) for the IPMH 7- and 30-day follow-up rates. This RCA revealed that Black/African American members were statistically less likely than their cohorts to have follow-up within 7 and 30 days. Despite this disparity, Black/African American rates improved from 2023 to 2024, with 7-day rates increasing from 32.7% to 34.1% and 30-day increasing from 50.6% to 51.8%. A previously established Health Outcomes goal was implemented to increase the 7- and 30-day follow-up rates of Black/African American members by 2% per year for three years. Based on the observed year-over-year improvement, this goal was met.

Community Care has implemented several interventions to improve follow-up rates for the general population as well as specifically for Black/African American members, which are listed below. Many of the interventions have been ongoing for several years, although most have been expanded or modified over time:

Community Based Care Management: Community Based Care Management is a Care Management program aligning with the Department of Human Services’ initiatives around whole-person healthcare reform. This initiative supports recovery by encouraging the use of preventative services, mitigating social determinants of health barriers, reducing health disparities, improving behavioral health outcomes, and increasing partnerships with Community-Based Organizations. Community Health Workers are an integral part of this program and are responsible for completing an Admission Interview with members to identify barriers to services and resources and to plan for aftercare.
Provider Performance Issues (PPIs): Community Care tracks aftercare appointments from all inpatient discharges as part of routine Care Management functions. The Quality Management Department collates this data to determine if members have aftercare appointments prior to discharge, and that those appointments are within 7 days of the discharge date. The data is monitored monthly, and Quality Improvement Plans may be requested from providers who trend for not meeting this expectation. The trend is then monitored for resolution. This intervention applies to both inpatient and aftercare service providers.
Aftercare Outreach: Community Care performs aftercare outreach to members discharged from acute levels of care to remind them of post-discharge appointments and assist with barriers to aftercare.
Admission Interviews: The Utilization Management Adult High Risk Care Managers conduct longitudinal care management and outreach to high-risk members who encounter difficulties maintaining stabilization and community tenure. The Care Managers meet with these members at inpatient mental health facilities and substance use disorder treatment settings to provide a face-to-face intervention. They complete the interview tool to assess strengths/needs, and collaborate with the treatment team and inpatient staff to address aftercare planning, coordination, and reduce readmission.
Inpatient Mental Health Provider Quality Improvement Activities: Community Care completes coordinated activities, including record reviews of mental health inpatient hospitals on an annual basis. These reviews focus on key factors necessary for successful discharge planning, including if a follow-up appointments.
Inpatient Mental Health Hospitalization and Ambulatory Services Shared Savings Model: Community Care implemented a value-based payment model in collaboration with providers and primary contractors in 2017. This model has continually expanded and currently evolved into a shared savings model for both IPMH and ambulatory services. Providers participating in this project may earn rate enhancements if pre-established goals related to follow-up appointments are met. These providers are also required to participate in regional collaborative activities focused on coordinating and improving follow-up rates. This shared-savings model also includes a community-based organization in each region that addresses social determinants of health such as housing, or food insecurity for members admitted to or have the potential to be admitted to IPMH services. Goals are determined by the contract-specific value-based purchasing arrangements, and for the 2024 rates, 24 of the 82 (27%) rates assessed met the goal for 7-day follow-up.
Network Expansion: In-plan services continue to expand to increase the range of aftercare options available to members. These may include mobile mental health services, certified peer specialists, mobile medication, ACT, psych rehab, school-based partial, etc. The continuum of crisis services may also be expanding to include walk-in and residential services.
Integrated Care Plan (ICP) - In alignment with Pennsylvania Department of Human Services’ goal for greater integration and coordination of behavioral and physical health services, Community Care engages in care coordination with physical health plans and documents these activities in an ICP. This ICP, or member profile, is used for the collection, integration and documentation of key physical and behavioral health information that is easily accessible. In addition, all Community Care contracts participate in grand round presentations with the Physical Health Managed Care Organizations, including United HealthCare, UPMC for You, Geisinger Health Plan, Gateway, Aetna Better Health, and AmeriHealth. The Care Manager completes an ICP template on each case presented in grand rounds.

In addition to the interventions above, Community Care also implements the following actions to address the found disparities:

The Health Outcomes Program: Community Care’s Health Outcomes Program reflects NCQA’s Health Outcomes Accreditation standards as well as Community Care’s efforts to improve the provision of Culturally and Linguistically Appropriate Services and to identify and reduce health care disparities related to race, ethnicity, gender identity, sexual orientation, and language. These factors are assessed for needs through many of Community Care’s Quality and Care Management Committee reports. Within this Health Outcomes Program, Community Care identified the aforementioned goal to increase follow-up rates for Black/African Americans by 2%. This goal will be maintained, along with a specific focus to:
Increase the number and proportion of care management interviews with Black/African American members during inpatient treatment
Facilitate specific linkage activities based on analysis of member interview responses regarding factors leading to admission, such as homelessness
Improve linkage to community-based aftercare treatment providers
Conduct member and provider outreach and educational initiatives

Furthermore, a Health Outcomes Committee was developed in 2021 to develop interventions to address inequities in three categories: Internal and Provider Professional, Member and Community Engagement, and Human Resources. Activities have included training on Culturally Competent Care for internal staff and providers as well as soliciting member/family feedback via the Member and Family Advisory Board meetings to inform activities and address disparities in care.

Community Care regularly monitors follow-up rates and data related to the effectiveness of the interventions. Data has consistently revealed effectiveness of the interventions, with increases in follow-up rates for members, including Black/African American members, who receive an Admission Interview and an ICP.