Behavioral health Discharge Action Plan: improving care transitions

Our goal

Empire BlueCross BlueShield HealthPlus (Empire) is dedicated to improving the health of our members as well as empowering members and providers to make informed decisions. To support this goal, we are committed to improving care transitions for all members who experience an inpatient behavioral health admission. We want to better equip members and providers to address the individualized needs of our members as they are discharged from an inpatient psychiatric or substance-use level of care to an outpatient provider. Through the creation of a Discharge Action Plan (DAP) for our Health and Recovery Plan (HARP) members, we are systematically addressing important, member-specific elements of discharge planning including psychoeducation around medication management, triggers for symptom recurrence, identified coping skills and aftercare appointment instructions.

 

How is the DAP created?

Our inpatient care managers collaborate with facility social workers to collect information on care transitions and use this information to complete an individualized DAP for each HARP member. From the moment of first contact with the inpatient facility, our care managers work collaboratively with providers to gather the information necessary to prepare a thorough and robust discharge plan. We have reshaped our inpatient review process to focus on critical elements of discharge planning that can create barriers to member engagement and follow‑through with aftercare. Together, with the inpatient facility, we work to identify what structure needs to be in place for the member to be successful in the community, what self‑management skills the member endorses and what barriers might be present that would prevent the member from successfully recovering in their community. We actively gather this information throughout a member’s admission resulting in an individualized DAP for each HARP member that can be shared with the member, their provider and other member-identified community resources upon discharge.

 

How is the DAP used?

The DAP is a resource for the member as well as all providers and community supports who engage the member following discharge from an inpatient behavioral health level of care. When the member discharges from an inpatient admission, our team of dedicated outpatient care managers contact the outpatient provider identified for aftercare and fax them a copy of the individualized DAP. The dedicated case manager shares a copy with the member and the health home and/or care management agency working with the member. The goal in sharing the DAP is to educate providers about the member’s medications, coping skills and barriers to engagement and provide the member with a comprehensive self-help tool to guide them immediately following their discharge.

 

Providing innovative solutions

Furthermore, we are committed to providing innovative solutions to some of the health care industry’s greatest obstacles. We know that follow-through with aftercare is one of the most significant barriers facing our members and success in aftercare is one of the leading ways to prevent future readmissions. We also know that lack of integration between inpatient and outpatient care remains a major barrier for our providers. Through the creation and dissemination of our individualized DAP, we hope to eliminate obstacles, empower all those we work with to better meet the needs of our members and better serve the communities in which we live.