Transition of Care Communication

1. Transition of Care Communication from the perspective of the outpatient clinic

2. Nystrom & Associates, Ltd. • Minnesota Based Mental Health Clinic with eight Minnesota locations and two Washington state locations. • Over 40,000 unique patient visits per year. • Patient population breakdown: • 50% State / Federal Funded (Medicaid / Medicare) • Large commercial payer mix (Blue Cross Blue Shield, Medica, Preferred One, Etc) • Small cash pay population • Collaborative partnerships with many MN, WA, and National Organizations: • Nexus (Mille Lacs Academy, Gerard Academy) • Prairie Care • Health Partners • Medica • Multicare Associates (Fridley, Roseville, and Blaine Medical Centers)

4. RARE – The Five Key Areas • Patient / Family Engagement and Activation • Medication Management • Comprehensive Transition Planning • Care Transition Support • Transition Communications

5. Patient / Family Engagement and Activation • Systemic communication is important from the start! • The value of the referring entity in getting Releases of Information. • Family System involvement expectations from point of referral on. • This is an active discussion and dialogue!

6. Medication Management • The importance of accuracy. • Dossing expectations and communication. • Existing medications • Cross Clinic / Provider illness management. • Additional resources – Family, Friends, Case Workers, Group Homes, Etc.

7. Comprehensive Transition Planning • Clear plan of services • What follow up, when, where, goals? • Communication of documentation and information from referent • Set up release of information and communication expectations with patient at this time.

8. Care Transition Support • Timelines for care – clear expectations on urgency (NCQA, Joint Commission, Patient Need) • Care needs, medication management, community services, psychotherapy, chemical dependency, etc. • The key to a good referral • Patient buy in, informed consent, clear communication and expectations

9. Transition Communication - The Culmination of the 5 Key Areas • Back and forth communication expectations. • Needs of referent, needs of the clinic, needs of the patient • Release of information on both sides.

10. Independent control – what are we able to take ownership of vs. what do we need to depend on other for. • Clear expectations on all areas from the start.

11. Collaborative Partnerships and Care Coordination • Value of formalizing collaborative partnerships • Use of a small handful of providers or one provider vs. many • Communication expectations – what to bring to the table

12. Time makes all things fuzzy • Over time memory fades. • Importance of writing it down. • Referral guidelines • Memorandum of Understanding • Contracts • Periodic review and check in • If it doesn’t work, FIX IT!

13. Clear expectations from day 1 Who is involved? How do they communicate? When it breaks, who is going to fix it? Did you write it down?

14. When good intentions fail • The “set it and forget it” mentality • Assumptions hurt patients care • Failure is an opportunity – Do not overlook it!