Transition of Care Communication

from the perspective of the outpatient clinic

Nystrom & Associates, Ltd. Minnesota Based Mental Health Clinic with eight Minnesota locations

and two Washington state locations. Over 40,000 unique patient visits per year. Patient population breakdown:

50% State / Federal Funded (Medicaid / Medicare)

Large commercial payer mix (Blue Cross Blue Shield, Medica, Preferred One, Etc)

Small cash pay population

Collaborative partnerships with many MN, WA, and National Organizations: Nexus (Mille Lacs Academy, Gerard Academy)

Prairie Care

Health Partners

Medica

Multicare Associates (Fridley, Roseville, and Blaine Medical Centers)

RARE – The Five Key Areas Patient / Family Engagement and

ActivationMedication ManagementComprehensive Transition Planning Care Transition SupportTransition Communications

Patient / Family Engagement and Activation Systemic communication is important from

the start! The value of the referring entity in getting

Releases of Information. Family System involvement expectations

from point of referral on. This is an active discussion and dialogue!

Medication ManagementThe importance of accuracy.Dossing expectations and

communication.Existing medicationsCross Clinic / Provider illness management.

Additional resources – Family, Friends, Case Workers, Group Homes, Etc.

Comprehensive Transition Planning Clear plan of services What follow up, when, where, goals? Communication of documentation and

information from referent Set up release of information and

communication expectations with patient at this time.

Care Transition Support

Timelines for care – clear expectations on urgency (NCQA, Joint Commission, Patient Need)

Care needs, medication management, community services, psychotherapy, chemical dependency, etc.

The key to a good referral Patient buy in, informed consent, clear

communication and expectations

Transition Communication - The Culmination of the 5 Key Areas Back and forth communication expectations.

Needs of referent, needs of the clinic, needs of the patient

Release of information on both sides.

Independent control – what are we able to take ownership of vs. what do we need to depend on other for.

Clear expectations on all areas from the start.

Collaborative Partnerships and Care CoordinationValue of formalizing collaborative

partnershipsUse of a small handful of providers or

one provider vs. manyCommunication expectations – what to

bring to the table

Time makes allall things fuzzy

Over time memory fades.

Importance of writing it down. Referral guidelines

Memorandum of Understanding

Contracts

Periodic review and check in

If it doesn’t work, FIX IT!

Clear expectations from day 1 Who is involved? How do they communicate? When it breaks, who is going to fix

it? Did you write it down?

When good intentions fail

The “set it and forget it” mentality Assumptions hurt patients care Failure is an opportunity – Do not overlook

it!