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Health System Management • December 2016

24 WWW.HEALTHSYSTEMMGMT.COM POPULATION HEALTH HEALTH SYSTEM MANAGEMENT | DECEMBER | 2016 “Patient-centered practitioners work on improving the patient-provider interaction through the use of measurable skills and behaviors.” includes behavioral health screening in primary care settings as well as physical health screening (medical history) in behavioral health settings with clear protocols for patient management and referral in each. Creating a shared treatment plan between physical health and behavioral health ensures all providers have access to goals, measurable objectives and progress at any given point. 2.Adopt data-driven practices to collect quantitative and qualitative information on patients throughout the care lifecycle. Health organizations are striving to achieve not only collaboration among and between services, but also to adopt quantitative data points to screen for symptoms related to behavioral health. It is imperative for providers to implement both qualitative and quantitative measures to make appropriate assessments related to patient functioning, problems presented and treatment/disposition recommendations. When a common language for symptom recognition and acuity is used between providers, there is improved communication and continuity of care. Examples of optimal data collection include the use of a patient health questionnaire (PHQ-2 or PHQ-9) in both primary care and behavioral health at designated intervals to assess for depression and suicidal ideation, as well as the Audit C to assess for high-risk alcohol use and GAD-7 to assess for anxiety disorders. 3. Develop sophisticated communication and collaboration policies to improve the continuity of care. Providers must collect and work from accurate, complete information regarding a patient’s health. They can then administer the best possible care, whether during a medical or mental health emergency or routine visit. Therefore, a system designed for sharing information among services both internal to the organization and external must be developed. Organizations should invest in information management systems that cross the silo barriers to provide relevant patient information to providers in real-time. Access to medical and behavioral health histories, medication lists, treatment plans and patient problem lists promotes a system of care that decreases the potential for patient decompensation and symptom escalation. 4. Create a system of efficient triage of patients to determine the severity and acuity of their symptoms. Preventing hospital readmissions starts with determining symptom acuity with a system in place to enable patients’ access to care when they need it — not after conditions have progressed. Policies and procedures should be established to engage the resources necessary for timely access to assess- ment and treatment services. For example, when there is a process to screen for issues related to substance use and emotional health, early intervention and care can mitigate the development of more severe symptoms, allowing for better outcomes and reduced readmissions. 5. Deploy effective management and follow up with patients who miss appointments and/or drop out of treatment. Holistic disease management programs often look to incorporate multi-system providers to allow for a seamless treatment delivery process. This system of care typically involves a comprehensive team including a case manager, a physician, a behavioral health provider, an RN and others. This team is responsible for collaborating on care to keep the patient on track for success. The continuity of care is greatly improved as providers from a variety of disciplines learn to work together for the good of the patient and overall performance of the health system. KEY TAKEAWAYS Coordinated or integrated health care delivery systems lead toward the goal of patient-centric care. The result: improved continuity and comprehensiveness of care, a focus on the relationship with the patient, improved access to care and evidence-based quality outcomes. Patient-centered practitioners work on improving the patient-provider interaction through the use of measurable skills and behaviors. This type of care can be used by providers in any specialty. These principles and practice management strategies effectively improve patient outcomes, thus preventing patient decompensation and hospitalization readmissions. REFERENCE 1. Roehrig, C. Mental disorders top the list of the most costly conditions in the United States: $201 Billion. Health Affairs. http://content.healthaffairs.org/content/35/6/1130 WEBEXTRA For further discussion of the challenge to lower readmissions in healthcare, read “Avoidable Hospital Readmission Rates Dropped in 49 States” at www.HealthSystemMgmt.com


Health System Management • December 2016
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