As accountable care takes hold, behavioral health organizations can expect to take a more prominent—and trusted—role in health system integration. In doing so, providers and their patients are likely to reap significant benefits in some surprising ways.
A core element of the emerging accountable care concept is improving clinical coordination as patients move among providers, sites of care and levels of care. Such handoffs involve more than just giving a patient a referral. They also require engaging the patient’s support system so that they are aware of treatment plans and the patient’s comprehensive needs—in context.
“This is a huge issue and one of the areas in which we fall down badly as a field,” says David Gastfriend, CEO of the Treatment Research Institute. “And it is probably responsible for a great deal of basic relapse.”
The concept is straightforward, although, in practice, handoffs involve many moving parts. Most difficult is the transfer of provider responsibility during the transition.
“The idea is that you are accountable for patients’ care, whether they are coming into or going out of your system,” says Virna Little, senior vice president of psychosocial services/community affairs at The Institute for Family Health. “This accountability lasts until that patient gets to that alternate level of care and has a successful interaction.”
For example, if a hospital is discharging a patient to a community program, the behavioral healthcare organization becomes responsible for that patient as soon as the first appointment is made.
“This patient is now my patient, even though I may never have seen him before,” says Little. “If the patient doesn’t keep that appointment, this new thinking says that I am accountable for that patient, just as if he has been my patient for many visits.”
That means following up with the patient directly and engaging with the support network. A warm handoff can involve in-person interaction.
“The program receiving the patient can send someone from that clinical team to the program that is discharging the patient, and meet the patient face to face, conduct a follow-up assessment and orient the patient as to what to expect,” says Gastfriend.
This can be done by professional staff, recovery support services, a paraprofessional or even a volunteer from the receiving program, he says.
Little says she advocates for an accountability protocol in which an outgoing handoff requires a direct conversation with a clinician at the receiving program.
“This should involved a full download of patient data, as if that receiving clinician is a member of the patient’s current treatment team,” she says.
Incentives to change
The question is, how motivated are behavioral healthcare organizations to make the necessary changes to support this approach to accountable care? Currently, there aren’t clear incentives for organizations to change, not to mention, large-scale infrastructure to support responsible handoffs would come with a steep price tag.
Typically, there is no accountability for a program releasing a patient if there is no warm handoff. If patients relapse later, the program might not even know about it, much less be accountable for it, says Gastfriend. Also, smaller behavioral healthcare organizations are unlikely to have the resources to begin offering warm handoffs.
While a more accountable approach makes sense in the big picture of healthcare, it is also a daunting prospect for behavioral healthcare organizations that believe they are already understaffed and overworked. Add in the fact that logistical coordination tasks are not likely to be reimbursed—at least not right now—and it’s understandable why behavioral providers are reluctant to operationalize accountability in the handoff process.
“Programs are overworked, and they are not incentivized for this today,” says Gastfriend. “Until incentives and compensation are designed to foster this communication, this activity will depend on programs’ clinical integrity and dedication to excellence.”
Accountability has value
Interestingly, market forces could be the impetus for change. Handoffs and care transitions are of great interest to potential investors as they seek out the comparatively better positioned organizations, experts say.
For example, when private equity firm Bain Capital acquired CRC Health in 2005, CRC Health worked to improve the number of patients who successfully made it to the organization’s step-down intensive outpatient programs within 10 days, says Gastfriend. Before discharging patients who had completed treatment for opiate dependence, the organization offered them one Vivitrol (naltrexone) injection to help prevent relapse.
“They doubled their success because patients had not relapsed,” says Gastfriend.
Within 10 years, Bain Capital sold CRC Health for a considerable profit.
This type of focus on handoffs is likely to become more common in the future as other behavioral healthcare organizations find themselves on the radar of large investment houses. In response, organizations need to determine how accountability might differentiate their programs from the rest of the market, making them more attractive.
“These investors are all looking at quality of care, improving patient retention and the warm handoff in the continuum of care as ways to add value and boost their profits,” says Gastfriend. “That is going to be a huge competitive lever that forces all of the programs that survived in this new economy to upgrade their quality of care, including the handoff.”