Follow-Up after Hospitalization for Mental Illness (FUH)

Why is it important?

Upon a Member's discharge from an inpatient hospitalization with a mental health diagnosis, MBHP aims to appropriately connect them to outpatient supports. This transition, when successfully managed, allows providers to monitor the mental status of the individual, review and fine-tune their medication regimen, and ensure patient safety. Early follow-up maximizes coordination between settings and reduces the likelihood of readmission.

How is it measured?

MBHP monitors performance improvements and outcomes by using HEDIS measure specifications to assess if Members 6 years of age or older are receiving follow-up care after discharge from inpatient hospitalization from a mental health condition. MBHP tracks improvement rates with the following two measures to assess our performance against national benchmarks:

1.	7-day Follow up: The percentage of Members 6 years of age and older who have an outpatient visit with a mental health practitioner within 7 days after discharge from an inpatient hospitalization
2.	30-day Follow up: The percentage of Members 6 years of age and older who have an outpatient visit with a mental health practitioner within 30 days of discharge from an inpatient hospitalization

How does MBHP perform compared to Medicaid providers nationally?

The table below presents MBHP's FUH performance rates compared against 2021 national Medicaid benchmarks in the 50th, 75th, and 90th percentile.

*MY 2022

Based on MY 2022 rates on FUH, MBHP's rate of 42.5 percent for 7-day follow-up met the 50th percentile national Medicaid benchmark of 38.0 percent, and MBHP's rate of 64.2 percent for 30-day follow-up met the 50th percentile of 59.6

Performance Goal

MBHP will aim to meet the following MY 2023 year-end goals:

7-day follow-up rate: Meet the 75th percentile national Medicaid benchmark of 46.1 percent.
30-day follow-up rate: Meet the 75th percentile national Medicaid benchmark of 67.1 percent.

What are our current improvement initiatives?

MBHP's Quality Department continues to work collaboratively with internal and external stakeholders to identify strategies and solutions for improving follow-up after 7- and 30-day discharge to enhance care coordination that will ultimately lead to improved health outcomes. Current efforts include the following:

Integrated Care Management Program (ICMP): ICMP is an enhanced care management program offered to Members with complex medical, mental health, and/or substance use disorders. Those enrolled in this program are assigned an ICM clinician who has a direct relationship with the Member and provides consultation about behavioral health and medical health issues. The aim of this high-touch service is to ensure that Members receive integrated health services that address the Member's complex needs. If a Member enrolled in, or eligible for, ICM services is hospitalized, the ICM clinician is notified so that they can outreach to the Member and provide support to engage in follow-up care and optimize the Member's health and wellbeing.

Hospital to Housing (H2H) program: Members dentified as high utilizers of inpatient services and experience chronic homelessness offered referral to the H2H program, which supports Members in gaining access to stable housing and outpatient mental health services. Access to stable housing is a critical component for preventing readmission to an inpatient setting, sustaining engagement in aftercare services, and experiencing longer community tenure in integrating back into the community. MBHP's transitional support service providers assist Members in receiving permanent supportive housing programs, as well as MBHP services.

Enhanced Care Coordinators (ECC): ECCs are independently licensed clinicians who provide clinical service care coordination to identified Members who experience high utilization of both psychiatric inpatient and 24-hour substance use disorder services. Many of the Members who have ECCs are also actively involved with other state agency services and programs; frequently utilize Emergency Departments (EDs) or Mobile Crisis Intervention (MCI) services; and/or have co-occurring medical and behavioral health diagnoses. The ECCs ensure the integration of services through ongoing communication with the provider(s) involved in a Member's treatment and establish linkages to family service agencies, community services organizations, the court system, schools, external care management providers, and other appropriate resources. The goal of ECC is to promote clinical service coordination in order to improve aftercare engagement, community tenure, and overall health outcomes for Members.

Hospital Liaison Program (HLP): HLP collaboration is key in helping our Members increase community tenure and our inpatient hospitals decrease their readmission rate. This program embeds an MBHP Care Manager onsite to support the inpatient psychiatric hospital treatment team with discharge planning. The Care Manager will be able to educate and discuss services available to Members, assist with barriers to discharge, help with coordinating with state agencies, and support in access to care issues.

Open Access Expansion: MBHP providers offer Open Access to improve access to care and to increase provider capacity to providing follow-up care for Members. The Open Access program allows providers to reserve a number of appointment time slots for walk-in appointments and enables Members to schedule and receive an appointment on the same day they call in order to improve access and relieve barriers to appointment follow-up. Open Access is defined as same-day scheduling, whereby Members access intakes, psychiatry services (i.e., medication evaluation and management), group meetings, or individual therapy in a more timely manner. This enables Members to schedule and receive an appointment on the same day of their request, which can improve access by reducing barriers to appointment follow up such as wait times. In 2019, MBHP updated the Massachusetts Behavioral Health Access (MABHA) website to include a directory of providers offering Open Access appointments. This technical update shares the availability of Open Access appointments with inpatient providers in real time, supporting their ability to schedule same-day aftercare appointments for their patients. MBHP continues to promote the use of Open Access to Members and increase availability of providers offering Open Access in 2021.

Aftercare Arranged and PCC Notification at Inpatient Discharge: MBHP asks all inpatient provider sites to complete discharge report forms for any Member who is discharged from an inpatient mental health hospitalization. MBHP uses small tests of change to measure the form's effectiveness and to intervene when data suggests a gap in administration or care delivery. Specifically, MBHP uses custom measures to assess the percentage of inpatient providers who arrange Members' aftercare and notify the Member's PCC prior to discharge and appropriately complete the discharge form. The rationale for the measures is that having complete discharge information will assist both the Member and their treatment team to access and engage in follow-up care in a timely manner. To successfully meet the measures, the provider must demonstrate documentation of the following elements in the discharge summary: Member and/or family involvement and agreement; name of the behavioral health covered service; name of the provider; date of follow-up appointment; time of follow-up appointment; and type of PCC notification. The results suggest that MBHP has an opportunity to improve follow up and care coordination by educating both inpatient providers and PCCs on the importance of their role in the behavioral health care pathway.

Provider Profiling and Quality Summits: MBHP is committed to increasing transparency on our quality performance; therefore, we support and prioritize sharing how we perform against HEDIS rates annually. MBHP creates FUH Provider Profile Reports to show providers the rate at which their Members receive follow-up in 7 and 30 days and shares comparisons against national benchmarks, other provider groups similar in size, and providers in the region. On a quarterly basis, MBHP's Provider Quality Managers (PQMs) share profile reports with all inpatient providers with 20 or more Members in the FUH denominator during a 12-month rolling period. The report includes a run chart indicating how the provider currently performs on 7- and 30-day follow-up rates, compared to their historic performance and MBHP's overall performance. It also includes a calculation of the number of Members the provider would need to engage in follow-up care to meet the next highest NCQA benchmark and a list of tips for improving FUH rates.

Provider Strategic Plans: In addition to sharing the quarterly HEDIS FUH rates and the quarterly performance on aftercare-arranged documentation, the PQMs work with providers to identify opportunities to improve the discharge process and implement projects related to identified opportunities. MBHP has set a threshold of 80 percent compliance with elements related to discharge planning. Therefore, when providers do not meet this target, PQMs develop quality improvement plans (QIPs) in partnership with providers aimed at improving the rate of arranging aftercare post discharge. Compliance and timeliness for completing the required fields on the discharge form are critical for supporting not only the aftercare-arranged measure, but also the 7-day, 30-day, and 90-day readmission measures. In addition, timely entry of discharge information on ProviderConnect is important for supporting MBHP's initiative to provide aftercare reminder calls to Members following discharge from inpatient admission/readmission, an intervention with known success.

Through the use of "Provider Strategic Plans," these standardized strategic plans allow each PQM to use the same format and methodology to establish rapid-cycle quality improvement with their respective providers. Each strategic plan must address the following key elements of quality improvement:

Clearly defined goal ("SMART" goal);
Intervention(s) that address root cause of the problem/barriers;
Action (tasks) to implement the intervention(s) with timeframe/responsible persons; and
Outcome measurement and re-measurement.

What can I do?

Partnering with MBHP: If you are interested in collaborating with MBHP on initiatives to improve follow-up care for Members discharged from inpatient care for a mental health illness, please contact the Quality Department.

Follow best practices for treatment following hospitalization for mental health:

•	Schedule an appointment before discharging a Member from a mental health hospitalization.
•	Discuss the Member's treatment plan with them at discharge.
•	Begin discharge planning at admission.
•	Arrange a transition visit for the Member at the time of discharge. Transitional services address the many barriers that prevent Members from successfully seeking and receiving care.
•	Link the Member to a Community Support Program (CSP) provider while the Member is on the inpatient unit. Members should be connected to a CSP in their region, regardless of the location of the inpatient admission.
•	Encourage the Member to sign a Release of Information form so that you can communicate with other providers who share in the care of your Member.
•	Work with the Member's natural supports to assist in their aftercare.

Resources

Communication between Behavioral Health Providers and Primary Care Clinicians "Two Way" Communication Form:
The Primary Care Clinician (PCC) Plan and the Massachusetts Behavioral Health Partnership, along with Carelon, have collaborated to create a single form that can be used by all MassHealth providers to facilitate communication. Behavioral health providers and PCCs can use the form when communicating with one another about a MassHealth Member. The primary purpose of this quality improvement initiative is to increase the frequency and improve the quality of communication between a Member's behavioral health provider and PCC.

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Access the Two-Way Communication Form

Daily Discharge Form:
MBHP has worked to encourage inpatient providers to submit daily discharge forms online in a timely manner through provider outreach and education. PQMs share compliance rates in daily discharge form submissions with network providers regularly.

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Access the Daily Discharge Form and instructions

Provider HEDIS FUH Rate Requests:
If you are interested in learning more about your HEDIS FUH rate as a provider, contact the Quality Department below to to request this information.