Best Practices: The Washington Heights Community Service Model: Positive Outcomes and Implications for Reimbursement Under the ACA

The Affordable Care Act (ACA) provides support to reform public systems of health care delivery. Among its mandates is the improvement of outcomes and treatment coordination between settings for people with chronic illnesses, with dedicated funding of, for example, patient navigators (1). The New York State–operated Washington Heights Community Service (WHCS) comprises a 23-bed acute-care inpatient unit and three outpatient clinics, where a multidisciplinary team model of comprehensive care has resulted in low readmission rates and other positive outcomes, despite the absence of external funding. We describe our model of care and its effects and implications and offer guidance to other programs.

Factors affecting rehospitalization

Numerous studies have described factors that increase rates of rehospitalization for people with mental illness. One report summarized demographic and clinical factors (2). Although there is consistent evidence that younger people are readmitted more frequently than other age groups, studies disagree about the effects of gender and ethnicity. Having a substance use disorder, a psychotic disorder, major depression, or a personality disorder has been found to predict psychiatric readmission. Other clinical factors include the number of prior psychiatric admissions, low level of functioning, severity and persistence of symptoms, medication nonadherence or partial adherence postdischarge, degree of insight into illness, medical comorbidities, and certain additional characteristics, including developmental disability, formal thought disorder, and a history of violence. A smaller literature has focused on social or environmental factors associated. These include stress and increased psychosocial problems, difficulty with housing, lower socioeconomic status, and lack of familial support (2,3).

Factors that reduce psychiatric readmission rates include coordination between inpatient and outpatient caregivers, family involvement, community follow-up, length of inpatient stay, and use of certain medications (2). Findings are not consistent about the effect of follow-up appointments, but clinicians and researchers generally agree that patients given follow-up appointments after discharge have lower rates of readmission, and a short interval between discharge and the aftercare appointment is recommended (4). Further, patients who are discharged without discharge planning, for example, without a family meeting before discharge or discussions about living arrangements and finances, are more likely to require readmission (2,5). The literature is inconsistent regarding length of stay (2). Some studies have noted that second-generation antipsychotics, in particular clozapine, can reduce readmission rates (6). Finally, adopting a therapeutic approach based on patient self-determination in both inpatient and outpatient settings may lead to lower rates (7).

Despite numerous studies examining factors that affect readmission, little information is available about real-world programs that effectively achieve low readmission rates in the context of flat budgets. No studies have shown that a single intervention or a standard bundle of interventions is consistently effective in reducing 30-day rehospitalization rates (8).

An innovative program

The WHCS, which is located in northern Manhattan, provides psychiatric care to 1,000 adults. On the basis of 2012 data, most patients are of low socioeconomic status (95%), are from racial-ethnic minority groups (82%), are primarily Hispanic (62%) and non-Hispanic black (19%), and have a psychotic spectrum disorder (56%) or mood disorder (39%). Of those with a psychotic spectrum disorder, 54% are taking second-generation antipsychotics, including clozapine (15%) and decanoate antipsychotics (10%).

Regarding risk factors for readmission, 65% of WHCS inpatients in 2012 were less than 40 years old, 60% had psychotic spectrum disorders, 23% had a documented substance use disorder, about 85% had medical comorbidities, and nearly 5% were homeless. Of note, the rate of psychoses among WHCS inpatients was approximately twice that among Medicaid recipients admitted in New York State the same year (9). Further, the average duration of illness among WHCS inpatients in 2012 was 11 years, with a mean of 4.5 prior hospitalizations.

We have developed a treatment model in which the inpatient and outpatient departments work together to enhance the quality of clinical care, with a focus on promoting active involvement among patients and families. Our model employs several elements shown to reduce rehospitalization and improve linkage with outpatient services (10,11). Patient care on all services is provided by a multidisciplinary team, consisting of psychiatrists, social workers, nurses, peer providers, occupational therapists, and trainees of all disciplines. Team members are flexible in undertaking tasks. For example, it is not uncommon for a psychiatrist to call a patient if he or she has missed an appointment or a social worker to conduct a home visit. Below we describe three key components of our innovative program.

Communication between inpatient and outpatient departments

Communication between inpatient and outpatient clinicians occurs in several ways. The WHCS has a shared electronic medical record (EMR), enabling inpatient and outpatient staff to view patients’ progress. On inpatient admission, staff review the outpatient notes and contact the outpatient treating clinician within 24 hours for collateral information. In addition to the EMR, communication occurs weekly when an outpatient social worker from each clinic attends one of the daily inpatient team rounds and gathers information about the clinical status of hospitalized patients to share with outpatient staff at their weekly team rounds. This two-way process facilitates the provision of feedback and guidance regarding treatment and discharge planning. An additional benefit is that clinicians come to know each other personally. The WHCS also holds an annual meeting, where all disciplines meet, in addition to discipline-specific trainings. This ongoing regular communication leads to a sense of a common mission and to professionalism and cooperation at all levels of patient care, in addition to staff retention.

Enhancing linkage to an outpatient clinic

Before discharge, new patients visit the clinic for an intake and often meet their outpatient treatment provider, and returning patients are escorted on passes to the clinic to see their outpatient provider, both to reestablish the relationship and for an assessment. Patients are given follow-up appointments within five days of inpatient discharge, and outpatient providers have immediate access to the discharge summary through the shared EMR. Upon discharge, patients are given only one or two weeks of medication instead of the 30-day supply often obtained from other hospitals in the area. The smaller supply necessitates a visit to the outpatient clinic soon after discharge to maintain medication continuity. Aggressive outreach to engage patients in outpatient care occurs after discharge. In the event of missed sessions, providers telephone patients or their family members and make home visits or initiate a mobile crisis referral when patients do not respond to phone outreach.

Involvement of family and others

Weekly family meetings on the inpatient unit are the norm and provide collateral history regarding the patient’s stressors and level of support. Interventions to enhance support and resolve conflict, such as psychoeducation and problem-solving techniques, are utilized when needed. Family engagement continues with passes home for the patient while hospitalized to ease the transition.

Collateral involvement at WHCS clinics includes family meetings and family therapy, often attended by multiple family members. Other individuals who know the patient, such as intensive and supportive case managers, visiting nurses, home health aides, and neighbors, are involved as needed on both inpatient and outpatient services and can be helpful for outreach and bridging care between discharge and engagement or reengagement with outpatient care. [A figure illustrating WHCS innovations to reduce rehospitalization is available in an online data supplement to this column.]

Readmission rates and other key outcomes

Medicaid data for 2012 indicate that the inpatient psychiatric readmission rate across all New York City hospitals was 16% (9). Despite the high risk of rehospitalization among WHCS inpatients, the 30-day readmission rate was 3% in 2012—less than one-fifth the average. From 2007 to 2012, 30-day readmission rates for the WHCS varied from 3% to 9% annually. Of people discharged to our outpatient clinics, 77% were seen within seven days, compared with 31% for all New York City Hospitals, and 88% were seen within 30 days. Only 8% failed to attend an outpatient follow-up appointment at WHCS clinics. In the past 12 months, only 6% of WHCS patients had four or more emergency room visits or inpatient hospitalizations, less than half the rate of area hospitals (13%).

Discussion

We have described a number of factors that may contribute to our low 30- day rate of psychiatric readmission, our low rates of emergency room visits and inpatient hospitalization, and our high rate of outpatient follow-up visits. In the absence of increased funding, these improved outcomes have occurred as a result of administrative support for redefined staff roles and expectations. For example, the outpatient staff member who attends the inpatient weekly team rounds is not expected to carry the same patient caseload as his or her outpatient coworkers. We recognize that not all settings can spare a staff member to perform this function, but other innovative approaches to coordinating inpatient and outpatient team rounds, such as telemedicine, can substitute (12).

Relatively long inpatient stays may also contribute to our low 30-day readmission rate. Over the past five years, the average length of stay has ranged between 24 and 32 days for patients with schizophrenia, which is higher than the New York State average of nine or ten days. Although studies in U.S. settings have had mixed findings (2), studies in other industrialized countries have shown that stays of less than eight days are associated with higher-than-average 30-day readmission rates, whereas stays between 25 and 30 days are not (13,14). Furthermore, a recent U.S. study showed that shorter hospitalizations lead to higher 30-day readmission rates (15). Evidence also suggests that the financial costs of longer hospitalizations are largely offset by lower readmission and emergency room utilization rates, not to mention less tangible benefits such as greater satisfaction with care, treatment retention, and improved quality of life (16).

Conclusions

Medicare and the ACA will base reimbursement partly on hospital readmission rates and other outcomes, but there is little guidance for providers to establish treatment protocols aimed at reducing these rates. Much has been written about factors that lead to psychiatric readmissions. However, less is known about real-world service models that implement and sustain feasible approaches to reduce rehospitalization. We have described a sustainable service model that may be generalizable to other settings. Proactive communication and linkage between inpatient and outpatient services by staff involved in direct patient care are essential. In our service model, ACA funding for patient navigators might well be redirected to other areas, such as the development of online patient tools to promote recovery (17). Other key features of the model are family involvement at all levels of care, community outreach, effective medication prescribing strategies, and a shared EMR.