Through data analysis performed in 2014 during our Follow-Up After Hospitalization for Mental Illness performance improvement project (PIP), we learned that administrative claims data alone was not capturing all of the follow-up care actually being provided. Follow-up visits at the Department of Mental Health's Designated Agencies (DA's) were not included in the rates prior to 2014. As you can see from the chart, once we incorporated those mental health follow-up visits our 2014 rate rose considerably.

This measure looks at continuity of care for mental illness. It measures the percentage of Medicaid beneficiaries 6 years of age and older who were hospitalized for selected mental disorders and who were seen on an outpatient basis by a mental health provider within 7 days, or within 30 days after their discharge from the hospital. The specifications for this measure are consistent with guidelines of the National Institute of Mental Health and the Centers for Mental Health Services.

It is important to provide regular follow-up therapy to patients after they have been hospitalized for mental illness. An outpatient visit with a mental health practitioner after discharge is recommended to make sure that the patient’s transition to the home or work environment is supported and that gains made during hospitalization are not lost. It also helps health care providers detect early post-hospitalization reactions or medication problems and provide continuing care.

• Medicaid beneficiaries and families
• Mental health practitioners
• Hospitals
• Department of Mental Health
• Department of Children and Families
• Department of Aging and Independent Living
• Vermont Department of Health

• Schedule follow-up appointments when a patient is discharged, as part of the treatment or case management plan.
• Educate patients and practitioners about the importance of timely follow-up visits.
• Consider reminder systems or “re-schedule” notices that are delivered to patients.
• Develop outreach systems or assign case managers to encourage recently discharged patients to keep follow-up appointments or reschedule missed appointments.

Vermont Medicaid is currently leading a performance improvement project (PIP) focused on improving follow-up after hospitalization for mental illness. All of the Partners mentioned above are involved in this PIP.