Readmissions reduced with psychiatric care

Patients stay out of hospital longer

Optum’s Field Care Advocacy program, which provides comprehensive services to people who are being discharged from a psychiatric hospital, has resulted in fewer hospital readmissions and longer periods of time between admissions.

Patients admitted to the hospital due to a behavioral health condition are often at high risk of being rehospitalized within 30 days after discharge because of a variety of factors, including the need for better coordination between medical and behavioral health providers and inadequate links to community-based resources and support, says Margaret Brennecke, PhD, national president for outpatient programs for Optum’s behavioral health business.

"To address this problem and promote the goal of recovery, the Field Care Advocacy program targets people who have recently been discharged from inpatient and residential settings who have been identified as being at highest risk for readmission. Our data analysis shows that the program helps decrease hospital rates and extends the time that people spend in the community between hospital visits," Brennecke says.

Based in Eden Prairie, MN, Optum contracts with employers, health plans, public sector programs and health care providers to support the needs of people with behavioral health problems.

Care for people in the program is coordinated by Field Care Advocates, who are independent licensed behavioral health clinicians who work with patients in person and over the telephone. Because they live in the communities in which they work, they understand the residents of the community and the services that are available. The Field Care Advocates have received extensive training from Optum Behavioral Health on engaging patients and tools and techniques that patients can use to manage their own mental and physical health.

Whenever possible, the Care Advocates make initial contact with patients while they are still in the hospital to introduce the program. Otherwise, they contact the patient immediately after discharge.

"When people are hospitalized for a behavioral health condition, it’s usually a traumatic and frightening experience. Nobody wants to feel that ill, and they don’t want it to happen again. At this point, they are open to making changes in their lives so this is often the best opportunity for the Field Care Advocate to go in and engage them in a plan of care," says Sue Bergeson, vice president of consumer affairs for Optum’s behavioral health business.

When patients have complex physical and mental health conditions, have experienced multiple hospitalizations and have had difficulty coping with their illness, they also may be assigned to a peer specialist who works as a health coach. They help the patients set goals and work with them on making lifestyle changes such as getting regular exercise or eating a healthy diet. The peer specialists are people who are in recovery from behavioral health conditions and who go through extensive training on engaging patients in managing their physical and mental health.

Optum’s Field Care Advocates work with people with behavioral health issues to ensure that they receive adequate therapeutic support and that the medical comorbidities are addressed. "We bring the concepts of recovery and resilience to the table and provide support so participants can learn to manage their own health," Brennecke says.

When patients are identified for the program, the Field Care Advocate conducts an assessment in four areas—therapeutic support, community and family support, medical comorbidities, and recovery and resilience. "We look at whether therapeutic services are available and if the patient has made appointments. If the services are in place, we make sure that all providers are aware of what others are doing, and that the patient is receiving effective, evidence-based care," Brennecke says.

The Field Care Advocates also assess whether the patient and/or family members need education and support and refer them to support groups, online sources, and other support systems.

When they conduct the initial assessment, the Field Care Advocates also assess the need for interventions for physical conditions. When there are medical comorbidities, the Field Care Advocate contacts the treating physicians and works to ensure appropriate communication between the patient’s medical and behavioral health providers. "Many times we find that physical illnesses are being under-treated because the patients are so focused on the demands of their behavioral health condition. To address that gap the Field Care Advocates coordinate with the behavioral health practitioners and physical health providers to make sure they are communicating with each other to meet all the patient’s needs," Brennecke says.

Often behavioral health providers and physical health providers work in silos and don’t know what the other providers are doing, she adds. "Our ultimate goal is to get patients aligned with services that meet their needs and get all providers communicating with each other," Brennecke says.

Bergeson adds, "The fourth pillar of the program, recovery and resilience, assesses whether, from the patient’s perspective, they are living a quality life and working toward goals that are important to them and whether they need support to enhance that," she says.

Typically, the Care Advocate works with the patient for 90 days but can extend the program if the patient needs it.

"The Care Advocate’s goal is to engage individuals, help them put a recovery plan in place, and step away. We don’t keep a member chained to our engagement because our goal is to help. We want them to take charge of managing their own conditions," Bergeson adds.

People who are paired with a peer specialist are identified when they come into the program. Typically, they have experienced multiple hospitalizations and have difficulty in coping with their illness and becoming engaged in adhering to their treatment plan.

Because the peer specialists have experienced hospitalization and treatment for behavioral health problems themselves, they have a good understanding of how these conditions can affect the physical and psychological wellbeing of the patients with whom they work. They often share stories of their own illness and recovery as they help patients identify their challenges and work through them. They typically work with patients for about six months, helping them develop recovery goals and support them in following the wellness and treatment plan the patient has developed with his or her providers.

"The peer specialists demonstrate the power of peer support in helping people improve their overall health and wellbeing. They work along with the rest of the team to ensure that the patients’ needs are met and that they continue to be able to stay in the community rather than being hospitalized," Bergeson says.