Although transition-of-care programs for patients with physical conditions exist, there are no such published cases, to our knowledge, on programs designed to serve patients with mental illnesses. The Emmi Behavioral Health Transition Series was designed to be a scalable interactive voice response (IVR)-based tool to help healthcare providers stay connected with people who had a primary or secondary psychiatric diagnosis and were deemed at risk for readmission. The overarching goal of the tool was to improve the transition from hospital to home over 4 weeks by empowering patients to manage their conditions. The IVR-based tool is deployed as a series of automated, interactive calls to patients once they transition back home to gather data on medication use and mood. Since behavioral health conditions often also affect friends and family, there is an adjunct “circle of care” series designed to help patients’ loved ones support their recovery. The calls provide options for the patients and circle of care to hear tailored information on topics such as nutrition, exercise and self-care, all areas that help with behavioral health.
Based on research that shows humans are willing to disclose more honest sensitive information to anonymous virtual humans (Gratch, Wang, Gerten, & Fast, 2007), we foresaw that an appropriately designed IVR call could help gather important health data that people might not be willing to tell their doctors. The tool needed to gather data on medication use and mood while still establishing a judgment free-zone.
The calls' tone and language had to be as de-stigmatizing and comforting as possible, so we worked with patients and therapists directly to review content and tone and ensure our approach would address any privacy concerns as well. In a world where people with behavioral health issues often feel misunderstood and isolated, and even at risk of losing employment, we wanted the calls to act as the essential link between patient and their doctors providing the communication needed to ensure a patient's wellness.
The project was commissioned by Houston Methodist Hospital and funded based on milestones by the Centers for Medicaid and Medicare Services (CMS) Delivery System Reform Incentive Payment (DSRIP) 1115 waiver, which aims to boost more-effective care transitions and offers project options to health care systems. The project is still being studied for effectiveness, but if it proves successful based on readmission data, it will look to be emulated at systems across the US. Thus far, Houston Methodist Hospital has published a paper with "Mental Health Clinician" explaining the program's structure and encouraging others to adopt use
Care transitions have always been a challenge for providers as they require valuable staff hours for care managers and nurses to reach out to numerous patients, gather/analyze various pieces of information, and make sure the right information gets to all the right people. Providers need to be able to efficiently identify and determine which patients who need extra help while still caring for the rest of their assigned population. After CMS began penalizing for readmissions, health systems became that much more committed to establishing effective transitions of care to solve the problem and have resources ready to commit.
As the tool is automated, it is cost-effective and scalable, making it easy to deploy across various organizations. Additionally, the technology platform used to deploy it allows organizations to analyze segments of the population and more easily focus on high-risk patients. The content and status questions were designed to apply to a wide range of behavioral health conditions, as well as accommodate the all-too-frequent scenario in which behavioral health issues also involve comorbidities with chronic health conditions. Also, as we understand behavioral health and low socioeconomic status often go hand in hand, the series was designed to assist those who may lack a stable home and financial resources.
After the calls, a survey is given to assess the patient’s engagement with the call and effectiveness of the information given. Thus far, we’ve enrolled 954 patients and connected with 75% of them. Results are very positive from the survey with the following patient responses:
• 78% felt better prepared to manage health
• 73% felt more comfortable calling their doctor about problems
• 61% found the information new and helpful
• 86% of the people who answered the first status question of their first call listened and
responded all the way to the end of the first call
• 59% of patients reported a red flag at some point in the series, alerting their provider about important issues like unfilled prescriptions, missed follow-up appointments, low mood, etc.
It is too early for Houston Methodist to have readmissions data on patients reached but their anecdotal feedback has been positive.