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Transition of Care Communication from the perspective of the outpatient clinic Nystrom & Associates, Ltd. Minnesota Based Mental Health Clinic with eight Minnesota locations and two Washington state locations. Over 40,000 unique patient visits per year. Patient population breakdown: 50% State / Federal Funded (Medicaid / Medicare) Large commercial payer mix (Blue Cross Blue Shield, Medica, Preferred One, Etc) Small cash pay population Collaborative partnerships with many MN, WA, and National Organizations: Nexus (Mille Lacs Academy, Gerard Academy) Prairie Care Health Partners Medica Multicare Associates (Fridley, Roseville, and Blaine Medical Centers) RARE – The Five Key Areas Patient / Family Engagement and Activation Medication Management Comprehensive Care Transition Planning Transition Support Transition Communications Patient / Family Engagement and Activation Systemic communication is important from the start! The value of the referring entity in getting Releases of Information. Family System involvement expectations from point of referral on. This is an active discussion and dialogue! Medication Management The importance of accuracy. Dossing expectations and communication. Existing Cross medications Clinic / Provider illness management. Additional resources – Family, Friends, Case Workers, Group Homes, Etc. Comprehensive Transition Planning Clear plan of services What follow up, when, where, goals? Communication of documentation and information from referent Set up release of information and communication expectations with patient at this time. Care Transition Support Timelines for care – clear expectations on urgency (NCQA, Joint Commission, Patient Need) Care needs, medication management, community services, psychotherapy, chemical dependency, etc. The key to a good referral Patient buy in, informed consent, clear communication and expectations Transition Communication - The Culmination of the 5 Key Areas Back and forth communication expectations. Needs of referent, needs of the clinic, needs of the patient Release of information on both sides. Independent control – what are we able to take ownership of vs. what do we need to depend on other for. Clear start. expectations on all areas from the Collaborative Partnerships and Care Coordination Value of formalizing collaborative partnerships Use of a small handful of providers or one provider vs. many Communication expectations – what to bring to the table Time makes all things fuzzy Over time memory fades. Importance of writing it down. Referral guidelines Memorandum of Understanding Contracts Periodic review and check in If it doesn’t work, FIX IT! Clear expectations from day 1 Who is involved? How do they communicate? When it breaks, who is going to fix it? Did you write it down? When good intentions fail The “set it and forget it” mentality Assumptions hurt patients care Failure is an opportunity – Do not overlook it!
