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 for relapse. The expectations are that all members discharged from an IPMH hospital will have a follow-up appointment within seven days. These measures include members with all diagnoses.

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 1 2024, Community Care completed a Root Cause Analysis (RCA) related to the IPMH 7 and 30-day follow-up rates. This RCA revealed that Black/African American members were less likely than their cohorts to have follow-up within 7 and 30 days. A specific Health Equity goal was developed and approved for implementation to address this disparity and increase the 7 and 30-day follow-up rates of Black/African American members by 2% per year for three years. Community Care will implement and monitor activities to address found disparities. From 2021 to 2022, follow-up rates demonstrated decreases for both Black/African American members as well as for White members; therefore, the goal was not achieved.

Community Care has implemented several interventions to improve follow-up rates for the general population as well as specifically for Black/African American members, including but not limited to:

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.

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 face-to-face intervention, complete the interview tool to assess strengths/needs, and collaborate with the treatment team and inpatient staff to address aftercare planning, coordination, and reduce recidivism.

In 2024, Community Care started the Integration of Care Management Optimization Initiatives project, which focuses on enhancing the efficiency and effectiveness of Care Management activities that support positive member outcomes and align with company goals. In its current draft, the project includes an optimization focus area of reducing readmissions by promoting medication assisted treatment prescribing in residential and inpatient settings and decreasing residential substance use disorder against-medical-advice discharges.

Community Care completes coordinated record review audits of mental health inpatient hospitals on an annual basis. These audits focus on key factors necessary for successful discharge planning, including if a follow-up appointment was scheduled within seven days. A Quality Improvement Plan may have been requested if the provider did not consistently meet the expectation.

Centers of Excellence (COEs) were launched in 2016 to expand access to counseling as well as other treatments such as Medication Assisted Treatment (MAT) (i.e., Methadone, buprenorphine, or naltrexone). COEs offer members diagnosed with an Opioid Use Disorder (OUD) peer support throughout all stages of recovery as well as Care Management to assist members in identifying, receiving, and sustaining treatment.

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. In 2022, 36 distinct inpatient mental health providers and 94 ambulatory providers participated in the value-based processes across the Community Care contracts. Providers participating in this project may earn rate enhancements if pre-established goals related to follow up 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 will address social determinants of health such as housing, or food insecurity for members admitted to or have the potential to be admitted to IPMH services.

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.

Community Care, in partnership with county partners, will continue to implement Community Based Care Management. 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 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 of 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.

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

A Social & Racial Justice Steering Committee was developed in 2021 to develop interventions to address inequities in five categories – Provider Professional Development, Internal Professional Development, Member Level Advocacy, Human Resource Interventions, Community, and Policy. Activities have included outreach to Black/African American providers for network inclusion, internal trainings on Cultural Competency, and a survey of providers to facilitate referrals that align with members’ preferences, such as having a same race counselor.

Community Care has developed a Social Determinants of Health Workgroup as part of the Community Based Care Management initiative. This workgroup is currently adding race, ethnicity, language, age, and gender to reports related to social determinants of health and Community Based Organizations to better identify disparities related to needs. In 2023, the workgroup determined the need for increased Community Based Organization engagement of Community Care’s Black/African American members to address Social Determinants of Health. One significant way that Community Care’s Care Managers connect members with Community Based Organizations is through Admission Interviews. Due to this, the workgroup established two goals, 1) to increase the rate of Community Based Organization engagement for Black/African American members who identify a social determinants of health need, and 2) Increase the proportion of Admission interviews for Black/African American members that have an inpatient admission. To impact this measure, Community Care included Black/African American members as a priority population targeted for admission interviews.

Community Care asks practitioners if they would like to disclose their race/ethnicity or religion to be used during its referral process, and if they have any area of specialization during the credentialing and re-credentialing process. Practitioners who choose to disclose this are identified within Community Care’s network accordingly. When members call Community Care’s Member Line requesting like-race practitioners or practitioners specializing in minority populations, Customer Service Representatives are able to see this information when searching for providers in the member’s region.

Community Care’s Health Equity Program reflects NCQA’s Health Equity 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.

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