As an extension of the 10th Scope of Work care transitions project, MPRO was awarded a Special Innovation Project by the Centers for Medicare & Medicaid Services offering an opportunity to focus on a unique patient population. Patients presenting with chronic health illnesses and potentially debilitating behavioral health conditions, such as diabetes and depression or heart disease together with a substance abuse disorder (SUD) are typically not adequately identified and addressed through traditional care delivery models. These comorbidities often inhibit a patient’s ability to successfully manage medications, understand self-care requirements and navigate post-acute care, thus increasing the frequency of hospital readmissions.
This toolkit is presented as part of MPRO’s Behavioral Health Initiative (BHI) aimed at reducing readmissions of patients with comorbid physical and behavioral health conditions and improving coordination of care across multiple settings. Root cause analysis among BHI participants revealed providers struggle to effectively care for patients with comorbid conditions due to unreliable information transfer, unsupported patient activation and a lack of standard known processes. Providers expressed the need for a comprehensive resource document to guide process improvement efforts and address care coordination for this patient population. The guide is divided into three main sections:
I. Identification and screening for behavioral health care problems
II. Communication between all stakeholders in assisting the person to recovery
III. Next steps for referral and follow-up
The toolkit contains narratives and embedded resources to assist providers in establishing an efficient screening process, enhancing communication skills and effectively coordinating care for the patient beyond the current care setting.