Care Transition Interventions That Facilitate Connections With Community Providers And Decrease Hospital Readmissions-Presentation Q&A

Video Transcription
Video Summary
In this video, Dr. Smith answers questions related to peer support in healthcare and the use of tools to stratify patient risk for readmission. Regarding peer support, Dr. Smith explains that CMS did not initially approve payment for peer support in physical health settings, but several states, including Georgia, began paying for behavioral health peer support in Medicaid programs. He emphasizes that peer and family peer services for mental illness and substance use have been proven to be evidence-based practices and that progress has been made, particularly with Medicaid programs and home and community-based services. <br /><br />As for tools to stratify patient risk for readmission, Dr. Smith acknowledges that most tools have been developed for the med-surg population with chronic medical conditions. Though he is not aware of validation studies for particular tools in the mental health field, he believes such tools are necessary. He encourages the use of tools like the readmit tool if it works for the clinical team.<br /><br />Dr. Smith also addresses questions about the effect of attending follow-up appointments on readmission rates. He explains that attending visits within seven or 30 days has been validated to reduce readmission rates, but cautions against considering it as a sign of success or true engagement in community-based care. He suggests the need for engagement measures that study patterns of receiving outpatient care over a minimum of six-month blocks of time.<br /><br />Lastly, Dr. Smith discusses the challenges in finding community resources and the issue of confidentiality in healthcare. He recommends checking with state mental health authorities, NAMI, and other provider coalitions for resource information. On the topic of confidentiality and patient autonomy, he explains that HIPAA actually allows clinicians treating the same patient to communicate with each other without written informed consent, and that clinicians should feel empowered to engage with patients and involve family members or support persons when necessary. Dr. Smith further acknowledges the limitations of quality measures like HEDIS, which may not capture the full extent of care management efforts. He concludes by highlighting the misalignment of incentives in healthcare and the need to redesign payment systems to better incentivize care transitions.
Keywords
peer support
healthcare
patient risk stratification
readmission
Medicaid programs