BH IPF Collaborative Newsletter March 2018

Comprehensive Transition Planning Recommendations Part III
Recommendations for Patients with Mental Illnesses:

Research shows that people diagnosed with a severe mental illness die between 10 to 20 years earlier than the general population and are also more likely to have chronic medical conditions such as diabetes, hypertension, or heart disease. Disregarding preventive care and the medical needs of a person diagnosed with a mental illness can place them at risk of earlier occurrence of developing a chronic disease and at greater risk for a hospital readmission. If a person with a mental illness does not have a primary care physician or clinic, help them obtain one for the purposes of not only preventative care but also for screening, management of chronic conditions, and physical health needs.

Special Considerations:
  1. Assist the patient with making an appointment to see a medical provider
  2. Ensure transportation is available to get the patient to the appointment
  3. Facilitate a warm hand-off with the medical provider when possible
  4. Communicate with the medical provider: 
  • Provide discharge summary/paperwork
  • Facilitate a release of information between the medical provider and your facility for communication and coordination purposes
  • Enlist the medical provider's help in encouraging the patient to follow through on  recommended mental health treatment including medication adherence, attending appointments, etc

The following should be addressed in the primary care follow-up:
  1. Preventive measures such as immunizations
  2. Orientation to long-term health and lifestyle issues
  3. Frequency of follow-up needed
  4. Patient goals for overall health such as tobacco cessation, exercise, weight loss, etc.
  5. Provide brochures, websites or phone numbers for information topics most pertinent to the individual patient
Additional Sources:
This material was prepared by GMCF for Alliant Quality, the Medicare Quality Improvement Organization for Georgia and North Carolina, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
Publication No. 11SOW-GMCFQIN-G1-18-12