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 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 statistically 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. The follow-up rates for Black/African American members have demonstrated consistent decreases with 7-day follow-up rates of 40.0% in 2021, 35.2% in 2022, and 32.7% in 2023 as well as 30-day follow-up rates of 58.2% in 2021, 54.9% in 2022, and 50.6% in 2023; therefore, the goal has not been achieved. It is notable, however, the follow-up rates for most subpopulations decreased. For example, White member follow-up rates also demonstrated decreases, from 43.8% in 2021 to 41.7% in 2023 for 7-day, and from 65.1% in 2021 to 62.0% in 2023 for 30-day.

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, with the first two interventions (Care Management Optimization Initiatives and Community Based Care Management) as the newest interventions:

Care Management Optimization Initiatives: 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. The Clinical Department regularly monitors related data and adjusts interventions associated with this initiative in real time, as needed.

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 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): 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 peer support to members diagnosed with an Opioid Use Disorder (OUD) throughout all stages of recovery as well as Care Management to assist members in identifying, receiving, and sustaining treatment. The number of COEs in Community Care’s network has more than doubled, growing from 36 providers in 2023 to 80 locations by 2025.

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 2023 rates, 12 of the 64 (19%) 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. From August 2023 to August 2024, improvements are noted across several levels of care, with a net total of 729 new providers and/or new locations added to the network across in all contracts.

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 Equity Program: 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. Within this Health Equity 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 Equity 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 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.

Social Determinants of Health Workgroup: 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 determinant of health need, and 2) maintain parity for 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 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 ICP.