Use of motivational and educational techniques in behavioral health patients to impact self-care and emergency department visit rates

Abstract

Background and objective: People with mental health and substance use disorders present with multiple medical comorbidities, social and legal issues. Due to these care complexities, this patient population has high rates of hospital readmissions and emergency department (ED) visits. Patients with mental health disorders require integrated care, which is the coordination of physical and behavioral health care. These patients may benefit from various educational techniques and counseling including the Teach Back Method (TBM) and motivational interviewing (MI). Houston Methodist Hospital (HMH) Behavioral Health Transition of Care Program, a quality improvement program, utilizes educational tools and counseling techniques during inpatient and post-discharge phases to improve care coordination in patients with behavioral health conditions. One of the goals of the program is to contribute to a reduction in the behavioral health/substance abuse diagnosis ED visit rate at the participating HMH system hospitals. For the first year (April 2014 through March 2015), the goal was to reduce the behavioral health ED visit rate by 5% from baseline (October 2013 through April 2014). This paper aims to 1) provide evidence to enhance motivation and establish partnership with patients, 2) report on the Behavioral Health Transition of Care Program’s use of motivational and educational techniques, 3) describe the program’s patient demographics from June 2014 through March 2015, 4) report program performance data, and 5) report ED visit data of patients with a primary or secondary behavioral health or substance abuse diagnosis.

Methods: Data for two of three HMH hospitals participating in the Behavioral Health Transition of Care Program are reported. Staff members carrying out interventions include social workers, educators, nurse practitioners, and a clinical pharmacist. Patients are eligible for inclusion in program interventions if they have a current or previous mental health or substance abuse disorder and are at high risk for readmission (determined by the Discharge Decision Support System [D2S2] conducted by the floor nurse). Social workers are consulted on high risk patients to conduct a Personal Health Record (PHR) and Morisky Medication Adherence Scale (MMAS-8) and enroll patients in the post-discharge interventions (telephone calls, home visits, or both). The clinical pharmacist is consulted on inpatients with a low MMAS-8 for coaching and medication education. After discharge, enrolled patients receive follow-up automated telephone calls. Educators call patients with post-discharge issues reported via these calls. Nurse practitioners conduct one to two home visits over the 30-day post-discharge period. Aggregate data was obtained using reports obtained for quality-improvement purposes. Descriptive statistics are reported.

Results: Of the 2,330 high risk encounters at HMH and San Jacinto Methodist (SJ) over June 2014 through March 2015, the average age was 55.8 years old, 4.68% encounters were insured by Medicaid, and the average D2S2 score (range: 0-11) was 4.4. Social workers completed PHR on 73.61% of the encounters and 13.48% of the discharged encounters had home visits within 30 days after discharge. There was a 4.6% reduction in the behavioral health ED visit rate from baseline to first year.

Conclusions: HMH implemented a Behavioral Health Transition of Care Program that uses MI and the TBM to facilitate in reduction of ED utilization by behavioral health patients. Although the goal of 5% ED visit rate reduction was not achieved, various contributing factors such as a high demand but limited supply of primary care providers may impact the rate.