FLOW: Early results from a clinical demonstration project to improve the transition of patients with mental health disorders back to primary care.

Abstract

Access to mental health (MH) care is of paramount concern to U.S. health care delivery systems, including the Veterans Health Administration. To improve access, there is a need to better focus existing MH resources toward care for those most in need of specialty-level MH treatment. This article provides early results of Project FLOW's (not an acronym) approach to developing and evaluating electronic medical record (EMR)-based criteria to identify clinically stable patients and promote their effective transition from specialty MH back to primary care (PC). Implementation utilized a blended facilitation approach consistent with Integrated Promoting Action on Research Implementation in Health Services (iPARIHS). The Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework guided measurement of implementation outcomes. During FLOW, 424 unique MH patients transitioned from MH to PC; of those, only 9 (2.1%) returned to MH after that transition. Most of those patients (n ϭ 335; 79.0%) were first identified on the MH FLOW report, but 89 (21.0%) were other MH patients. The total number of patients discharged due to recovery or stabilization was 411. The 335 patients represent 21.3% of all unique patients (n ϭ 1,566) who met the EMR criteria during the project. The 411 recovered/stabilized patients are 16.4% of all unique MH patients (n ϭ 2,504) treated at the site. These early results suggest that this EMR-based system, combined with sound clinical practices, can be used to identify MH patients who are candidates for transition and foster their effective transition to care management in PC.

Transitioning patients from outpatient mental health services to primary care: A rapid literature review

“…One strategy to improve access is to transition patients with stable or low-acuity mental health conditions out of specialty mental health services and into primary care. Such transitions are consistent with recovery oriented care, which posits that recovery exists on a continuum of improved health and wellness (Bishop et al, 2016;Fletcher et al, 2019;Sheedy & Whitter, 2009;Smith et al, 2019;Stengel et al, 2012). This continuum of recovery often helps define when to "step up" care for patients requiring more intensive mental health services (Harter et al, 2018;Heddaeus et al, 2018;van Straten et al, 2015), but less frequently defines when to "step down" care for patients who no longer need mental health specialty services (Fletcher et al, 2019;Smith et al, 2019).…”

“…Literature searches resulted in a review of 3,761 abstracts and 29 full text articles ( Figure 1 ). Of these, only 11 articles met our inclusion criteria ( Berkowitz et al, 2018 ; Chang et al, 2014 ; Durbin et al, 2004 , 2012 ; Fletcher et al., 2019 ; Hamilton-West et al, 2017 ; Jespersen et al, 2009 ; Koenig et al, 2013 ; Noseworthy et al, 2014 ; Röhricht et al, 2017 ; Smith et al, 2019 ). Characteristics of included articles are summarized in Table 2 .…”

“…The most commonly described transition practice was patient engagement, with 10 articles describing the use of patient-centered approaches to engage patients as active participants in their care. For example, six articles described how mental health providers partnered with patients and elicited their preferences in determining whether to move forward with a transition to primary care ( Fletcher et al, 2019 ; Hamilton-West et al, 2017 ; Jespersen et al, 2009 ; Noseworthy et al, 2014 ; Röhricht et al, 2017 ; Smith et al, 2019 ). In addition, an NHS study in East London described a process of working with patients to help them identify their recovery goals and develop a recovery and transition plan based on those goals ( Röhricht et al, 2017 ).…”

“…Seven articles described the establishment of clear processes and responsibilities for the administration of psychiatric medications. For example, as part of the U.S. Department of Veterans Affairs (VA)'s FLOW initiative in South Texas, mental health providers ensured patients had at least a 6-month supply of psychiatric medications at the time of transition, and they instructed patients to contact their primary care provider at least 1 month prior to needing a refill ( Fletcher et al, 2019 ; Smith et al, 2019 ). In the Southeast England NHS project, responsibilities of the newly created role of primary care mental health specialists included providing patient education on medication adherence ( Hamilton-West et al, 2017 ).…”

“…This continuum of recovery often helps define when to “step up” care for patients requiring more intensive mental health services ( Harter et al, 2018 ; Heddaeus et al, 2018 ; van Straten et al, 2015 ), but less frequently defines when to “step down” care for patients who no longer need mental health specialty services ( Fletcher et al, 2019 ; Smith et al, 2019 ). This “stepping down” is critical for improving access, because when stable patients transition to primary care, outpatient mental health providers have more capacity to meet the needs of new patients and those with high-acuity conditions ( Fletcher et al, 2019 ; Smith et al, 2010 , 2019 ).…”