Hello and welcome. I'm Amy Cohen, Associate Director for SMI Advisor and a clinical psychologist. I am pleased that you are joining us for today's SMI Advisor webinar, Care Transition Interventions that Facilitate Connections with Community Providers and Decrease Hospital Readmissions. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. And now I'd like to introduce you to the faculty for today's webinar, Dr. Thomas Smith. Dr. Smith is Chief Medical Officer, New York State Office of Mental Health. He's also co-director of New York State's Office of Mental Health Center for Behavioral Health Integrated Performance Measurement. And he's also a special lecturer in the Department of Psychiatry at Columbia University. He oversees clinical and quality aspects of the New York State public mental health system with a focus on improving access to prevention, recovery, and rehabilitation services for persons with serious mental illness. Dr. Smith, thank you for leading today's webinar. Thank you, Amy. It's my pleasure and good afternoon, everybody. I can't say it's good to see everybody, but it's good to know that there's a lot of people signed in. We've got good attendance today and hopefully you will find it worth your time and we'll have an interesting discussion. These are certainly interesting times now with the COVID epidemic and everything going on. So I will try to tailor the talk a little bit to the epidemic, although much of what we're going to be talking about today is going to be sort of bread and butter, routine discharge planning and care management or care transition interventions that improve connections to care for people coming out of the hospital. For disclosure, I do not have any relationships or conflicts of interest related to this presentation. Our learning objectives are as follows. We're going to talk about care transitions, people transitioning from inpatient to community-based care, what we know about them, and what we know about that risk period following discharge from an inpatient stay, and including the risk for readmission, not only readmission, but other adverse outcomes. We're going to talk about routine discharge planning, which includes things as listed there, things like communication between providers, scheduling appointments, forwarding discharge summaries. That's what we're going to refer to as routine discharge planning versus we'll also talk about more intensive care management interventions for people when it appears that routine discharge planning may be necessary, but not sufficient. That's what we'll be talking about. So let's dive in. Many people on the phone probably know this already. This is a very critical period of time when somebody is coming out of a hospital for treatment of an acute psychiatric condition and transitioning to care in the community. There's been a lot of research indicating that there's many different kinds of adverse outcomes that we want to avoid. First and foremost is a lack of engagement in care. A lot of people fail to transition and take up care in the community after their discharge, and when you see that, you're immediately going to be at risk for relapse and readmissions. We'll talk about those data coming up, but we also see very significant increases in risk for homelessness, criminal justice involvement, violent behavior, suicide. Rates of suicide are many times higher in the 30 days following discharge from an inpatient stay than otherwise. And then of course, even all cause mortality, there was a recent paper that came out just this year indicating that rates of mortality for all causes, including suicide, are higher in that period following discharge from inpatient care. So we always think of people going in the hospital as getting care and getting better, but with psychiatric individuals, coming out of that hospital is a very, very high-risk period. And these, as I mentioned, what is the standard of care? What do we expect out there in communities and hospitals regarding routine discharge planning? And this is generally what you see. If you look at the standards from joint commission, from CMS, hospital standards, there's an expectation that inpatient teams communicate with outpatient teams. There's expectations for scheduling appointments in a timely manner. In New York state here, we have a regulation where we try to ensure that all patients have discharge. They have appointments scheduled within seven days, one week of discharge from the inpatient stay. And then, of course, we should be forwarding discharge summaries or some sort of case reports to the outpatient clinicians. That's routine discharge planning practices that are widely accepted as standards of care. But what do we know? How often do people complete these practices? And there's not a lot of research on this. It's not like you can go to literature and find this out. It's not, for many researchers, it may not be a terribly interesting question. It's also not an easy question to answer. In New York, we've been doing research on this. We've been trying to answer the question. Here's some data from 2012, 2013. I'm going to talk a lot about data we have from the New York state Medicaid program where we did a quality assurance initiative back in 2012, 2013. And we tried to get managed care plans that were coming to operate in New York. We tried to get them to focus on doing quality assurance and quality improvement before we actually authorized them to start doing utilization review and paying bills. And we had the plans focus on discharge planning activities, working with hospitals to try to understand how often are these discharge planning practices happening. And when they're not happening, why not? These are some of the data that we found. And this was for over 30,000 people. These were Medicaid recipients with serious mental illness, hospitalized in a psych unit in New York state, and hospitalized on a psychiatric unit with a primary mental health diagnosis. In most of these analyses, we excluded people hospitalized with a primary substance use diagnosis, like a detox or rehab unit. Most of our data focused on people admitted with a primary mental illness, and the most common serious mental illnesses are schizophrenia and the schizophrenia related disorders, schizoaffective disorder, bipolar disorders, major depressive disorders, those kinds of illnesses. And what we found is that the inpatient teams were communicating with the outpatient teams for 62% of the cases when we looked at these 30,000 cases. Aftercare appointments scheduled within one week or five business days for 55%. And then having a case summary forwarded to an aftercare provider within a day following discharge in 75% of cases. Those are the data that we found. Not a lot of data to compare to in the literature. This is what we found at first blush. When we look at our care transition data, well, okay, with that kind of routine discharge planning, how well do people connect with care? So we looked at, these are the common HEDIS measures, right? How often do people attend an outpatient visit within seven days or within 30 days of discharge for inpatient care for a mental illness? And what you're seeing here are a national HMO managed care data. Those are HEDIS measures data versus New York state, what we call the mainstream managed care Medicaid program versus the New York state fee-for-service program, which the fee-for-service are still the people with, it's basically the SMI population, people with serious mental illness. And look at these rates. I mean, people attending a visit within seven days following discharges, somewhere between 31 to 54% within 30 days is 44 to 71%. So think about that for a minute. So upwards of 40 to 50% of people coming out of a psychiatric unit, being discharged and transitioning to the community, don't see a mental health provider in the 30 days following discharge. It's really quite striking. And the, well, let me just say this, ask yourselves, I think everybody on the phone, if anybody was admitted to a hospital, let's say you had your gallbladder out or you had an exacerbation of diabetes or a heart pain or God forbid, a heart attack, something like that. And you were in the hospital for five days, seven days, three days, what have you, what's the odds that you would, following discharge, that you would not see a doctor for an entire 30 day period after being admitted for something, for acute inpatient care? I think the odds, I'll speak for myself, the odds are low, close to zero, we'd be following up. But we don't see that with people with mental illness coming out of psych units. We see a good 40 to 50% of them to this day, not following up. And these HEDIS measures, by the way, are probably the most widely used quality or performance measures for behavioral health. And most people on the phone are probably familiar with them because your hospitals are probably talking about them. We need to document and follow up and see if we can get these visits, get some documentation of people attending visits within seven or 30 days. Managed care plans across the country are being measured on these measures and being compared. Many managed care contracts have financial incentives for achieving these measures. CMS and the Joint Commission and CMS has included measures related to discharge planning in the PQRS program and some of their quality initiatives. So there's been a real focus on care transition outcomes from a quality performance measurement perspective. This is probably the area in mental health, the area where there's been the most effort to develop quality and performance measures. And despite that, despite that focus over the past 10 years, these numbers haven't budged that much. They have not gone up. And there's a lot of questions about why that is. If you look at our friends in medical care or med-surg care, all these quality measures, people are probably familiar with how quickly, if someone has pneumonia, how quickly do you get started on an antibiotic if you go in the hospital? If you have a heart attack, how quickly do you get started on a beta blocker? Things like that. These quality measures have been out there now for 20, 25 years. And many hospitals across the country, and Medicare publishes these results, these hospitals easily get now up above 90% on most of these quality measures. They've been able to do that. And many quality measures are being retired, if you will, because the sense is that the treatment community has done the best they can. They've really hit the ceiling. But at the same time, we can't budge this measure. This is the most commonly reported behavioral health quality measure, and we can't budget. Why is that? It's a question that hasn't been answered. And then, of course, if people are not doing well, they'll get readmitted. So here's the data that we dug up on 30-day all-cause readmission rates. So all-cause means you're coming back into the hospital, essentially for any reason, right, all-cause, following a discharge. There are data for mental health readmission rates, where you come into the hospital for a, you're discharged from a mental health unit, and you come back in with a mental health primary diagnosis. And the numbers are quite similar. It really says the same story. The story here is that readmission rates for individuals with serious mental illness are consistently higher than those for people who don't have a serious mental illness, for people getting admitted for med-surg, or for mild to moderate behavioral health conditions. And these rates are 19 to 25%. So one in four people coming out of a psychiatric hospital with serious mental illness is readmitted within 30 days. And for the most part, experts would agree that a readmission is generally not a good thing. You don't need to come back in the hospital, but think about a hospitalization again. Think about yourself. Hospitalizations are disruptive, and your entire life gets put on hold. So it's one thing to need to go in the hospital, but to keep cycling in and go in again and again, it's not a good thing. And we really need to work harder to see if we can change these numbers. So to summarize, this is what we just talked about. So this period following discharge is a very high-risk period. Much higher rates of suicide, violence, criminal justice involvement, et cetera. Yet what do we see? Only 50%. If you look at all three of those routine discharge planning practices from our research here in New York, only 50% of discharged individuals with serious mental illness get that comprehensive discharge planning. Only half have an appointment scheduled, a case summary forwarded, and some sort of communication between the inpatient and outpatient teams. And again, only half of them attend an aftercare visit within 30 days of discharge. And a quarter of them end up readmitted in that same period. So we're not doing well. There's work to do here. We need to figure out what interventions work and what populations, what patients need more than routine interventions. These are the challenges for us. Does routine discharge planning work? And if so, why aren't so many people getting it? And when does it not work? When is it insufficient? I don't think we would make the argument that some people should not get routine discharge planning, although some clinicians may believe that. And when it's insufficient, what are the intensive care transition interventions that can be considered? What's available to these individuals? So let's dive in. It's routine discharge planning work. And believe it or not, there's also not a lot of data on that. It's not something that researchers have dived into. It's hard to do a lot of research in this area. It's hard to get into medical records and find out exactly what's being done in terms of discharge planning, and then to link that to data and information about how well people follow up. It's not easy work to do. We have a project here in New York. We've been working on it for the past four years now, really digging into this group of discharges from 2012 and 2013 and trying to understand that. And here's data from our study. This is unpublished data. This really looks at people who had an appointment scheduled versus those who didn't have an outpatient appointment scheduled. That's simple practice. Was there evidence that the inpatient team scheduled an aftercare appointment for the individual? And these are survival curves. So it starts off at zero, and we're talking about the probability of people attending a visit. So at day zero, which is the day of discharge on the left side there, nobody has attended an outpatient visit yet. So everybody's at zero. And then as time goes by, you see 10, 20, 30 days, you can see increasing numbers of people who have attended a visit. So if an outpatient appointment was scheduled, that's the red line. You see that that line shoots up much higher so that by 10 days, 50% of people have attended a visit. And by 30 days, it's up closer to 65%. So that's much better. If no outpatient appointment is scheduled, you see that group lags. By 10 days, only 25% of people attended a visit, and by 30 days, it never really gets much above 40%. So that suggests this very simple activity, scheduling an appointment, has an impact in and of itself. And we've done some pretty sophisticated analyses that we're going to publish shortly that suggest that if you start to control for all the other factors, because clinicians will say, well, yeah, they attend appointments, but the people who don't have appointments scheduled, well, they have substance use issues, or they left the hospital against medical advice, or they weren't in the hospital long enough to set up an appointment, or they don't want care, what have you. Even for controlling for many of those characteristics, we find the same thing, that scheduling an appointment works. So this next slide, this is complicated. These are propensity score strata. This is looking at the same data we just showed you, but taking all those groups, or taking both groups, the blue group are people who did not have an appointment scheduled. The red bars are the people that did have an appointment scheduled, but we split it out into five groups, or what we call propensity score strata. Each group is a stratum, and the groups are distinguished based upon the patients that are having other characteristics that predict a poor follow-up following discharge. So that group one over there, where the bars are the lowest, those are the people that have the greatest number of risk factors for poor follow-ups. These are people, homeless, substance use, co-occurring substance use, right? The primary diagnosis for all these populations was a mental illness. We're talking about people with a primary serious mental illness, but a lot of them have co-occurring substance use, we know that. So that group one over there is the people that have the highest risk for not following up based upon co-occurring substance use, homeless, very short lengths to stay, having a lot of other medical problems, et cetera. And even in that group, you can see that scheduling an appointment has significantly improved the chances of attending a visit. And all the way up in each of these groups, each of these strata, you see that scheduling an appointment had an impact. And when you get all the way to the far right, it's the population with the least number of risk factors for poor follow-up, and you see the rates of attending an appointment are higher. They are close to 50% within seven days. These are the seven-day discharge likelihood. So it's a common scenario. A lot of clinicians will say, oh, we know this person, the person doesn't follow up, they never follow up, they haven't followed up in the past, or they weren't engaged in care before they got in the hospital, or they have an active substance use. So we know they're craving substances that they're not really ready to stop using. We know it's unlikely that this person is going to follow up. Well, even in those people, our data suggests that the routine discharge planning has an impact and you should do it anyway. Getting an appointment in there, giving the person an appointment, giving them that information seems to have an impact. I know there's a lot of hospitals out there that might have policies that if a patient signs out involuntarily, puts in a request for discharge letter and says they want to go home, and then most states, I think all states have statutes that say if someone requests a discharge, then you have to let them go home unless the treating psychiatrist feels there's some imminent risk to themselves or somebody else, and then they can file papers to have the person held involuntarily. So I know a lot of hospitals, whether it's formal or informal, will have policies or approaches that if people sign out and say they don't want to be in the hospital and they want to leave, and they're not in imminent danger, so the doctor has to discharge them. I think a lot of hospitals have a policy for those people. There's no need to do discharge planning if the person wants to go. I think our data suggests otherwise. Even for those people, I say, you want to go, you don't want any more treatment, fine. Let us at least get you an appointment and give you the name of a clinic, aftercare provider. It seems to help. This really says the same thing. This is on a sample from the same time period where we broke out these three discharge planning activities, right? Providers communicating to each other, sending a discharge summary, and scheduling an appointment. And we grouped the people coming out of the hospital based upon whether they had none of those discharge planning activities were done, that's the top line, versus the only having one, having any two of them, or having all three. And here, our survival curve is reversed, where at the time of discharge, 100% of the people have not had an outpatient appointment, we switched it around, But then over time, you can see that people start attending outpatient appointments. And it's the same thing. The more of these discharge planning activities that were provided, the greater the chance people were going to attend visits. Okay. The other point about this slide, the reason I'm showing it, is if you look at it, the lines separate, right? Up at the left, all the lines are mushed together. And then they start separating over time. But the separation is equal by about 10 days, somewhere in that seven to 10-day period, you see that full separation. And then from then on, throughout the rest of the 45 days, the lines are all the same distance apart from each other. So that suggests that the impact of this routine discharge planning is really within the first 10 days or so of discharge. And that makes sense, right? When we're talking about faxing a discharge plan, or scheduling an appointment, or having a phone call with the outpatient doc, if that's going to have an impact, it's really going to be in the short term. That's really all about getting people connected right away in the next seven to 10 days. And we wouldn't expect these routine discharge planning activities to have a significant impact 30 or 40 days after the person leaves the hospital. All sorts of things happen to you after you leave the hospital. So the impact of this routine discharge planning is really in that first 10 days. And again, that underscores the idea, the notion that we should try to be getting these appointments scheduled right away after discharge. So who's not getting this? What patients are less likely to get this routine discharge planning and therefore are more vulnerable? And these are some preliminary data from that same study that we looked at. And this is not that surprising, right? People who have the shorter lengths to stay. We do see a signal for racial ethnicity, ethnicity indicating that African-American and Latino populations may be less likely to have appointments scheduled. The homeless population, those with a lot of co-occurring medical conditions, which was an interesting finding to us. And then of course, those who don't participate, who didn't participate in care prior to the admission. One of the strongest characteristics of whether someone, or one of the strongest predictors of whether someone's going to follow up after a hospitalization is whether they were in care before they got in the hospital. And people who were not in care are less likely to follow up. That's a very powerful predictor from prior studies. But although, remember what we talked about five minutes ago, even in those groups, people who had routine discharge planning were more likely to follow up than those who didn't. We found some trends and interesting potential findings related to hospitals in service system characteristics, like rural hospitals tended to have lower rates of people getting comprehensive discharge planning. That may have to do with availability of providers, right? In rural settings, there's not as many providers available. Interestingly, and these are New York data, we found that teaching hospitals, large hospitals and teaching hospitals tended to have lower rates of discharge planning. And that was sort of was counterintuitive. We thought that larger hospitals or teaching hospitals would have more resources, more people interested in doing stuff with patients like discharge planning. We didn't see that. So it may be that these larger teaching hospitals, maybe they have more sicker patients or more patients with other characteristics that suggest they're less likely to get discharge planning, although we control for all those variables. So an interesting finding. So what do you do, right? What do you do for the people where the routine discharge planning may not be sufficient? There's been a lot of talk over the past 10 years about these kinds of follow-up and outreach activities, like doing needs assessments and pre-discharge education and doing telephonic follow-up and trying to have more communication, follow-up communication between the providers and then outreach when people fail appointments, outreach either by the hospital or by the receiving entity. And these are all good ideas, I think, and a lot of these activities really originally developed in the medical field, med-surg units. But it's not clear that they're sufficient for people with serious mental illness. And most experts feel they're probably not. But let's digress a little bit on that point. There are care transition models. Our colleagues in medicine and surgery were onto this probably a little sooner than we were in mental health. I'm speaking from the quality improvement or performance measurement perspective. I think it was about 25 years ago that there first became some serious interest in readmission rates amongst the Medicare population, elderly with chronic medical conditions, because these people were quite ill, number one, and number two, very costly. If you look at Medicaid and Medicare populations, 5% of individuals are responsible for 50% of all the costs of health care. So economists and experts started really looking at this, again, going back about 25, 30 years ago, and found that there were certain populations of the elderly, people with multiple chronic conditions that were responsible for multiple readmissions, had those high readmission rates, 20% or so, and were driving a lot of the costs and the quality. So that's when our medical surgical colleagues developed a lot of these quality measures related to readmissions, preventable readmissions, and successful care transitions in those populations. And sure enough, the expert clinicians developed intensive care transition approaches to help move those needles. And they've been successful at that. So some of you who work in hospitals may have heard of, these are three models, the transitional care model. Mary Naylor at Penn developed this model. Project RED, which is about re-engineering discharge planning. Again, these are for Medicare med-surg patients. And then the Care Transitions Intervention Program, Coleman and colleagues out of Colorado developed the model. So these are intensive care management approaches developed for Medicare populations with chronic medical illnesses. They have several core characteristics. There are a lot of nursing education, a lot of patient education prior to discharge, including engaging family members, a lot of focus on medication reconciliation, because many of these elderly patients are on many, many medications. People can be on 10, 15 medications at a time. And then a lot of telephonic outreach and follow-up post-discharge. These are the general characteristics of these models and they've proven to be quite effective. I summarize on the slide here that readmission rates have dropped by 30, 40% and engagement rates increased by 30% or similarly. So these have been proven to be effective in med-surg populations. One of the points I want to make is that I don't think we can just transfer those initiatives straight to an SMI population. People with serious mental illness have some different and unique needs. They often have functional deficits in multiple domains. And then they have a range of cognitive deficits, including things like paranoia, delusions, reality distortions, or some people just have real basic processing deficits, focus, attentional problems, short-term memory, working memory problems, social skill deficits. So a wide range of cognitive deficits that impact on their ability to follow up with treatment recommendations, take medications, et cetera. And thirdly, I think there's this issue of stigma and lack of training among healthcare professionals related to these patients' needs. Our med-surg colleagues like to remind us that patients can vote with their feet and if patients don't show up and then they choose to walk away from care, then that's fine by them. But I think for those of you who work a lot with people with serious mental illness, we know that we can't stop there. A lot of patients, because again, of their cognitive status and their complicated relationship with their illness and with their recovery, and their complicated relationships with the treatment system, which many treatment systems have not always been friendly to people with serious mental illness. So a lot of people will walk away from treatment recommendations and treatment opportunities and we shouldn't stop when that happens. We should try to anticipate that and work with them to try to keep more people in care. People with serious mental illness, they need care management. That is, this is what I was just saying, that is flexible, persistent, much more likely to be boots on the ground out in the community. A lot of people with serious mental illness do not typically respond to phone calls or to mails, letters in the mail, offering outreach and support. They need care managers that can have boots on the ground and be out there in the community and meeting them where they're at. And ideally care managers that are experienced working with people with a serious mental illness and can help people navigate difficulties they may have with some of these cognitive problems associated with illnesses. So care managers that understand how to do problem-solving approaches or understand some of the key elements of motivational interviewing to work with people, for example, with substance use issues who may not be at a point where they're ready to quit, but that doesn't mean they can't be in treatment. So we need care managers that really have some of these tools, have this experience working with people with serious mental illness and know the local behavioral health system of care. Care managers often have to broker relationships, broker meetings, go with some of these people to their initial appointments with clinics and do that literally warm handoff so that the client does meet the clinician and develops some initial sense of trust. And again, we need care managers that can promote a sense of recovery. I think too often we hear from our patients and our clients that the treatment system is very intimidating and is too medically oriented and treats them like patients that have chronic disabling conditions that are unlikely to improve. And the whole notion of treatment for so many people just creates a sense of hopelessness and lack of opportunity to live the kind of lives that they want. I think we need care managers who can say, no, that's not the case. Treatment is one of the many tools that you'll use on your path towards recovery. And as a care manager, I want to help you find the right combination of treaters and treatment options. I also want to help you make sure you have the most secure and safe housing arrangements and that you can develop this whole concept of a meaningful day, that you have a set of activities that to you are meaningful and important and allow you to feel that you're living the kind of life that you need. I think we need care managers with that kind of mindset and skills to help engage these people that are most difficult to engage. So what are our resources or opportunities for these kinds of interventions? And I list five here. There's many more, but these are five that most people on the phone, I hope, would have heard of. The fifth one, the opening doors, maybe not. That's a relatively newer model, but these are approaches that are out there. I think one of our goals today is to heighten people's awareness of the resources that should be available in many communities to support intensive care transition and offer intensive care transition resources for those people who are not connecting and for whom routine discharge planning does not appear to be sufficient. So let's go through them. Health homes, right? The health home program came into existence because of the provision in the Affordable Care Act and the states that adopted elements of the Affordable Care Act were able to offer incentives to providers to create these health homes and pay for health home care management and pay for care managers to be boots on the ground in the community, helping people get their care coordinated and organized. And these are the six core health home standards put out by CMS. So states, and if your state is one of them, that have adopted a health home program, the health homes in your state should be attending to these core standards. And the third one there that's highlighted in red is transitional care. CMS was on top of this. They said, if we're going to do this kind of intensive care management and pay for it in Medicaid programs, that we need to have a focus on care transitions. So health home providers should have systems in place to work with hospitals and facilities in their network to provide prompt notification of someone's admission to a hospital so that that health home care manager can get to the hospital, get involved and provide that intensive care management or care transition service that some of these people need. So if you have health homes in your state, try to engage health home care managers, call them, figure out who they are, call them and say, hey, so-and-so's in the hospital. This is a person, obviously, that may be having a hard time following up or hasn't followed up well in the past. Can you join our inpatient treatment team and help be part of the discharge planning process and provide the care transition support that the person needs? Those are health homes. The critical time intervention model, CTI, people may have heard about it. It was developed originally in New York by Dan Herman and some colleagues, and it's a model of intensive care transition services originally developed to support homeless individuals with serious mental illness coming out of hospitals. So not only were they at a psychiatric hospitalization, but they did not have stable housing. So the CTI model is a time-limited intervention. The original CTI model was designed to be a nine-month program of intensive care transition services following discharge. There have been brief CTI models adapted from the full model that are three-month interventions that have been tested and shown to be effective. The idea is you have a team of care managers. The team can be care managers just like health home care managers. A lot of care managers are bachelors trained, but ideally, they would be care managers who get this additional training in things like motivational interviewing, recovery models of care, engagement of individuals with serious mental illness. And it's a three-phase treatment services program. It's not a treatment program. It's care management. And the three phases have to do with phase one is implementing the transition plan while providing emotional support. This is the most intensive phase of the CTI model where the care managers are most intensively involved with the client. They try to get to the hospital before the client leaves, and they work with the client in the community as much as needed during those first seven, 14, 30 days to ensure a safe transition, try to limit the chances of readmission, really focus in on the housing supports, the basic financial supports, and safety during that period. That's phase one. Then they move into phase two, which might be within the second or third month, depending on the model, where they really start encouraging the patient to use his or her problem-solving skills and to access the support system. So now we've got a client who's in the community, in safe housing, somewhat settled. Okay, here, let's start navigating your community. Know your providers, know how to make appointments, follow up with appointments, know how to make sure you've got your money every month, know how to make sure you can track your food and groceries, et cetera, and start using your support system. Who are your supports? How do you use them? Let's start using them. And then you phase into phase three, which is a termination phase, because the whole idea behind this model is that the intensive care management is time limited, right? Some people need these models indefinitely, but many don't. The third phase of a CTI model is a termination phase, where the care management team turns over their care management responsibilities and their care coordination activities, turns them over to existing resources and providers in the community. They turn them over to the primary clinician in the clinic or to the depression care manager in the primary care practice or what have you. That's a critical time intervention model. Increasingly, we're seeing clinics and providers adopt these principles of critical time intervention. Assertive Community Treatment, ACT programs. ACT is an evidence-based practice that's available in many states. ACT is designed for people who we're talking about today, people who have a very hard time engaging in community-based care. They generally have difficulty attending routine clinic-based care. And they are people who are very, very high risk for multiple acute admissions, readmissions, emergency room visits. So the whole idea behind the Assertive Community Treatment model is to have a team that's in the community working with the client. So if you have ACT teams, ACT resources in your community, consider trying to use them if you can for care transitions with these complicated patients. And there's other models out there. I'm going to end in a minute, but I just wanted to say a couple words about this model, Opening Doors to Recovery, developed originally by the NAMI group in Georgia. And Michael Compton is a services researcher, along with Ben Drust and his team, that partnered with them to help develop and test the model. And this is the model where they have three community navigation specialists or navigators. One is a professional navigator, someone with some clinical training or training, mental health training, working with clients. One is a family navigator specialist and one is a peer. So an interesting team that focuses on linkages with hospitals, linkages with the police, the law enforcement community as indicated, and have a primary focus on reducing recidivism and promoting recovery. A very strong focus on this notion of developing a meaningful day that I mentioned earlier, as well as safe housing and engagement in care. So a very interesting model with some good data. This is the only piece of data I'll show. They've got other data, but they showed a dramatic reduction in numbers of hospitalizations for people that were enrolled in this program in Georgia in pilot study. So I'm going to try to stop. So we have time for questions and answers. So just to quickly summarize, this is what we know. These numbers are sobering. 50% of people coming out of the hospital do not get even routine planning. And sure enough, 50% fail to attend a visit and a quarter of all these people are readmitted. So we have work to do. Routine discharge planning works. It's still not completely clear why. A lot more people don't get it. But I think we should encourage clinicians out there to do it, even for patients that you feel are least likely to benefit from it. The data suggests that even for them, it works. It's clear that many people need more than routine discharge planning. And there are models out there. So look for those models in your communities and try to connect with them and get those resources available to these people. And then of course, as always, we need further refinements and testing of these interventions over time. And I'm sure that will happen because this is really an important area for our field. So with that, I'll stop and turn it back over to Amy. And I think we have some time for Q&A. Is that right?

care transition interventions

serious mental illness

inpatient care

community-based care

discharge planning

engagement in care

aftercare visit

care transition models