One of the most frequently reported behavioral health quality indicators is the HEDIS measure of percentage of outpatient appointments kept within 7 days of an inpatient psychiatric discharge. In its 2005 State of Health Care Quality report, the National Committee for Quality Assurance (NCQA) states that “Appropriate treatment and follow-up of mental illness can reduce the duration of disability from mental illness and the likelihood of recurrence.”1
Studies have identified inpatient facility practices related to higher rates of patients keeping follow-up outpatient appointments. These include:
presenting predischarge illness fact sheets combined with verbal reinforcement;
scheduling appointments as soon as possible after discharge2-4;
having staff contact the outpatient clinician before discharge5;
ensuring communication between inpatient staff and the outpatient clinician about a patient's discharge plan;
having the patient start the aftercare program before discharge; and
involving the family in treatment.6
Other studies have identified interventions not effective in improving aftercare compliance. These include:
having a predischarge, physician-led educational intervention7;
having the patient meet the outpatient therapist before leaving the hospital;
having the patient attend outpatient discharge groups8; and
using intensive care management strategies.9
Given the importance of aftercare engagement, Managed Health Network, Inc. (MHN), a managed behavioral health organization, compared the inpatient facilities in our network that achieved the highest rates of outpatient follow-up with those that achieved the lowest, with the goal of determining those processes that differentiated the two groups.
We calculated the rates for follow-up outpatient appointments held within 7 days of inpatient discharge for all facilities with at least 25 psychiatric admissions in 2004, and we selected the 10 with the highest rates and the 10 with the lowest. The highest follow-up rates ranged from 78 to 90% and the lowest from 38 to 48%.
We designed a set of 10 questions reflecting the use of best practices for ensuring follow-up appointments (Table 1). In telephone interviews, we asked representatives from all 20 facilities whether they used these practices. We then calculated the total number of affirmative responses by facility.
The average number of effective practices endorsed by facilities with high rates of outpatient follow-up was 8.3; the average for low performers was 5.1, a statistically significant difference. Interestingly, the facilities with the highest follow-up scores all endorsed 8 or 9 of the 10 best practices, while those with the lowest follow-up scores endorsed only 3 to 7 best practices. As shown in the figure, the facilities with high follow-up rates were more likely to have a policy statement that included the expectation of a follow-up appointment within 7 days. In addition, they were more likely to have discussed measuring outpatient follow-up rates with staff and to have assessed their own performance. These facilities also were more likely to have arranged aftercare appointments for their patients and to have given their patients a discharge card that included information about the appointment.
Facilities with high and low follow-up rates did not differ in other areas. Only 1 of the 20 facilities routinely called patients postdischarge to encourage or assist with aftercare. In addition, all facilities said that they involved families in the discharge process. Two facilities that mentioned limitations on family involvement (e.g., “with the patient's permission” or “if part of the treatment plan”) were both in the poorer performing group, and two that stressed the importance of including family in the aftercare process were in the better performing group. Several interviewees at facilities in both groups were unaware that the first follow-up visit could be with any behavioral health practitioner and did not have to be with a psychiatrist.
We found that inpatient psychiatric facilities with high rates of 7-day outpatient follow-up differed from those with low rates. Staff at high-performing facilities were more knowledgeable about follow-up standards, distributed information about the measure, and assessed their compliance. They were also more likely to arrange for patients' aftercare appointments and to distribute aftercare cards as reminders.
Sharing information about approaches used by high-performing facilities may help low-performing facilities to improve. Information could be shared in training sessions, individual contacts, or newsletter articles.
The authors acknowledge the contributions of Karin Wilson and Laurie Adams, MHN Professional Relations Associates, who spoke with and tracked responses from each facility, and Rachael Alexander, who did the data analysis.
The authors are affiliated with MHN: Jeffrey Schwartz, PhD, is Manager, Quality Improvement; Deirdre Hiatt, PhD, is Vice-President, Quality Improvement; George Hargrave, PhD, ABPP, is a Consultant to Quality Improvement; and Ian Shaffer, MD, MMM, is Chief Medical Officer.