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Care Transition Interventions That Facilitate Conn ...
Presentation Q&A
Presentation Q&A
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So some questions have been coming in already during your talk. Let me just pull them up. So why doesn't CMS approve payment for peer support in the physical health side? We can bill for behavioral health peer support, but we need to be able to bill in hospital settings to assure warm handoffs at discharge. That's an interesting question. I'm not sure I follow it completely. I mean, CMS did not approve peer supports at all, by and large. I think it was several states took the initiative in their state Medicaid programs. I think Georgia was one of the first to start paying peers, behavioral health peers, or mental health peers, in their Medicaid programs. And it got to the point, and there's been enough data, and most experts will now agree that peer and family peer services for people with mental illness, and also people for substance use, is an evidence-based practice. There's enough evidence indicating a benefit that I think most experts are now labeling these as evidence-based practices. In Medicaid programs, a big step forward was taken with the home and community-based services provision. Again, the Affordable Care Act had another provision in it that allowed states to start paying for home and community-based services for people with behavioral health conditions. Long story short, that was a way of getting services like employment supports, education supports, and peer supports paid for by Medicaid in behavioral health. So we've made tremendous progress on the behavioral health side. And again, states that have taken up those Affordable Care Act provisions can now pay for peers in their Medicaid programs. I know less about peers on the med-surg side, and I don't know if the question has to do with peers that have chronic medical conditions, or whether it's peers with lived experience with mental illness working in hospitals. But either way, I know little about CMS commenting on that, and I think it's a good question. It's something to look into. I'll think about that. I have seen almost nothing about CMS promoting peers for med-surg conditions. I really haven't seen that. Can you comment on the utility of using a tool to stratify patient risk for readmission? And this person suggests, for example, the readmit tool. Yes, there are several tools that have been developed. Most of them have been developed for, again, the med-surg population for people with these chronic medical conditions. And they are effective. That's the question. If we know that routine discharge planning is not sufficient for some people, well, how do we assess and determine who those people are? I don't think we have any good tests. I think that's the next phase of research on the mental health side, is to start testing some of these tools that have been validated with chronic medical conditions. But I'm not aware of validation studies for particular tools, although the short answer is, yes, we need those. That's where we need to go. And if the readmit tool works for you and your clinical team and you find it's helpful in the behavioral health population, I would not discourage you from using it. Yeah, and this person wrote back and said the readmit tool is one designed for psychiatric readmission. Okay, well, that tells you what I know then, right? Well, we're all learning. We're all learning. Another person wrote in, is there evidence that attending a follow-up appointment in either seven or 30 days leads to reduction in readmission or other recovery measures? Yes. I mean, the simple HEDIS measures of attending visits within seven or 30 days, they've been validated going back 20 years. And the main validation was a test of reduced readmission rates. So if people do attend a visit within seven or within 30 days, they are less likely to be readmitted. And that's a robust finding, and that's repeated, and that's good. However, what's not good is that people commonly refer to those as engagement measures, that this is a sign of success. If you get that single visit under your belt, then we're in business. Everything's going to be great. And I think most clinicians and experts will say that having a single visit in the first 30 days following discharge, while it does predict you're likely to stay out of the hospital, and that's good, it really doesn't say much at all about is the patient truly engaged in community-based care and getting services they need to really adequately address their illness and put them on that road to recovery. So there's a tremendous amount of work going on. Our group in New York, our Performance Measurement Center, is very focused on engagement in care measures that look at minimum six-month blocks of time and study patterns of receiving outpatient care to see if we can identify some thresholds of engagement where we can say that is someone who's really engaged in getting good care. We need to move beyond. We need to get more knowledge about just having a single visit. We can't be satisfied with saying if you have a single visit in 30 days, you're engaged in care. We have to do better. Great. So this question's a little long, but try to stick with me because I think it's a really good point here. So how do we even begin to find these resources in our community? I realize it's the responsibility of the discharging facility to set up these appointments and provide both the patient and the transition facility with pertinent information. If there's a point of contact for a patient, can they make the information available to them, meaning can the facility make it available to them? For example, is there basic follow-up information that can be given to the patient's caregiver or family member or support with the patient's permission? I think a couple of points there. One is every state's different. We have a funny health care system. We really have 50 health care systems, especially when you talk about Medicaid programs. So in any given state, there's different ways of identifying where the resources are and what the services and programs are. Every state has a mental health authority, some state-level agency that's either part of the Department of Health or a distinct Department of Mental Health or Department of Behavioral Health that should be making information available about services that it authorizes, that it licenses, or that it pays for. So you can always start with your state mental health authority. NAMI is really good at identifying resources in states and other coalitions of providers. A lot of the recovery-oriented support groups will know about things like recovery rooms, for example, things like that. You can get information anywhere and everywhere, but too often when you need the information, like on an inpatient unit where you've got a patient sitting in front of you, you can't get it easily. I sympathize with that issue. We don't have a national resource or database or place to go where anyone can learn what's out there. It's very unique state by state. I empathize with you there. I think the person's sort of wondering if, for example, when the person's discharged, let's say they have a power of attorney. Could the next appointment and where you expect them to go and connect, could that be given to the power of attorney or to a support with the patient's permission? Absolutely. I think that in many places in our communities and in our service systems, there's still a very, very narrow view of confidentiality and patient autonomy that so often works against the patient's best interests. The best example is providers talking about HIPAA. To this day, providers everywhere say, well, we've got these HIPAA regs and the HIPAA regs prevent us from communicating with other providers. We've got to have signed consents, et cetera, et cetera. If we don't have that, we can't do it. That's exactly the opposite of the truth. HIPAA created all sorts of regulations about how electronic health care information is shared. The big focus with the HIPAA regs was the fact that we're in the computer age now with all these billing programs, electronic medical records, et cetera. There's all sorts of ways that information can leak out. But an interesting element of the HIPAA provision, the HIPAA law actually states, because it wasn't stated clearly before and they put it in there. HIPAA clearly states that providers treating the same patient in any health care setting, providers who have treatment relationships and treatment obligations to a patient can and should communicate with each other and do not need written informed consent from the patient to do that. HIPAA says exactly the opposite of what many clinicians believe it says. Now, there are state regs that may be more restrictive than HIPAA. And there's also the 42 CFR Part 2 federal substance use reg that's very clear about consent for release of substance use related treatment information. So with those caveats, HIPAA actually gives more authority for clinicians and treaters to communicate with each other. And I think we err, there's no good way of saying this, but I think too often we err on the side of patient autonomy and confidentiality. And we see patients suffer by not following up, not getting resources, not getting their medications, what have you, when we know there are resources out there like family members who could easily fill in. I think that we need to work harder as a field to make sure clinicians feel empowered to work with patients, to engage significant others and support persons in their care, because absolutely that helps enormously. When looking at follow-up appointment at 50%, case management and support coordination are not included in the HEDIS measure and for housing and other social determinant services, which are provided by support coordinators and case managers. I think this person's point is that there's a lot done in case management that isn't captured in that measure, which is just do they have a follow-up appointment scheduled? Yep, yep. Yeah, in New York, we have a lot of conversations with NCQA with that HEDIS measure, because the HEDIS measure, and other states have had the same issue, that they don't allow, it's a measure, meaning there's a numerator and a denominator. The denominator is all the people coming out of a hospital. The numerator is people who followed through and had a documented appointment with a licensed practitioner, mental health practitioner. With HEDIS, their primary focus is to create a quality measure that's applicable across the whole country and across states. So they're on a tightrope. They need to have specifications that are relevant and apply to all states, so you can compare apples to apples. But if you go in individual states, and care management is the best example, individual states all have different kinds of care management programs that they would argue, this should count in my HEDIS measure. Well, it might look good in Missouri, it could count, but no other state has a care management program like Missouri's. I made that up with Missouri. So there's no way that that HEDIS measure would be valid anymore if they allowed for that kind of flexibility. So there's a real struggle there with the HEDIS measures, and NCQA, I think they're doing a great job. They're doing what they've got to do, but it's a shortcoming when you start talking about quality measures should be used for CQI, continuous quality improvement. So when you're doing your CQI projects, you might start with a HEDIS measure, but then you want to drill down and you want to bring in all this other stuff that you do in your state, in your network, in your hospital that matters, because it does matter. You know, getting care coordination, care management is good, and that counts towards a successful transition. So it's that tightrope run with quality measures. I know we need to go, but can I just, I really want to ask this question because I think it's really practical. This person writes in and says, we try to do all of our discharges within seven days, meaning see them. But our problem is we aren't getting information on when someone's discharged. They call and call, and there's no documentation. The discharge summary, the meds they're discharged on, the labs, the psyche valve. Any tips on how to get that info from the inpatient site for these people who are working in the community who are receiving this person back? Yep. Yeah, we see all scenarios out there. We see scenarios where the hospitals have all the information ready, but the community-based providers are not available to accept it. And then we see this scenario where community-based providers are ready and willing to respond, and then the hospitals don't have that information. I think the issue is that our incentives are not aligned, right? If the inpatient treatment team had the same incentives as the outpatient team, and a lot of this gets into issues of quality improvement and performance measurement and reimbursement. There's this big push nationally to move towards value-based payments. So the experts will tell you that the answer is to restructure the payment systems so that the incentives are aligned. So if the hospital knows that it's going to get a higher rate and get paid more money if that patient connects with the outpatient provider within seven days, and that outpatient provider knows that it also is going to get a financial bonus or a higher rate of payment for that connection, and the incentives are aligned, then guess what? Both sides will start exchanging the information. But right now, the incentives are not aligned. The hospital is probably overwhelmed with so many discharges that it can barely keep up with them and has to, you know, it's putting all their attention on new admissions, and they just don't have the resources, and there's no incentive in it for them to follow up and make sure that the outpatient provider gets that. That's a problem in our healthcare system. Incentives are not aligned, and that's our starting point. Maybe that's a good ending point for us now, and maybe a future webinar we could do on value-based approaches because the experts believe that's the answer here, to redesign payment schemes so that the incentives are aligned and providers get on the same page, and care transition is a perfect example of something that should be better incentivized in value-based arrangements. I think that's the best I can say. Thank you so much, Dr. Smith. I really have enjoyed this, both your talk but also this meaty conversation at the end, and I think our audience has as well.
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
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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