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 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 2023, Community Care completed a Root Cause Analysis (RCA) related to the IPMH 7 and 30-day follow-up rates. This RCA revealed that members who were Black/African American and non-Hispanic were less likely than their cohorts to have follow-up within 7 and 30 days. Community Care has implemented several interventions to improve follow-up rates across the network, 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.

Community Care’s care managers may meet with members who are on an inpatient unit to identify barriers in attending follow-up appointments, address concerns, and facilitate discharge planning. This intervention was expanded to include children as well as other priority members, for example, members who may have readmitted over the standard 30-day readmission timeframe, members who are at risk of having a readmission, or members who are pregnant, etc.

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’s Care Management team helps individuals with an OUD navigate the health care system by facilitating initiation into OUD treatment from emergency departments and primary care physicians; helping individuals transition from inpatient levels of care to ongoing engagement in community-based treatment; and facilitating transition of individuals with OUD leaving state and county corrections systems to ongoing treatment within the community. To ensure the success of the COEs, Community Care provides regular data reviews to the COEs via monthly webinars.

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 IPMHs 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.

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.

In 2021, Community Care developed a Targeted Accessibility Analysis to identify gaps in same-race or culturally competent treatment availability for Community Care’s Black/African American members. Using GEOAccess software, Community Care plots geographical information regarding the drive time or the distance members in rural and urban locations must travel to get to a specific type of provider. Member race/ethnicity information from DHS enrollment data is applied to their geographical location. This data shows gaps in same-race or culturally competent providers reasonably accessible to Community Care’s Black/African American enrollees. The Targeted Accessibility Analysis has been applied to Allegheny County, but a plan to expand this intervention to other contracts is underway and may also include the Hispanic population in contracts where the Hispanic population accounts for more than 10% of the membership.

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.