The document describes a pilot program between Abbott Northwestern Hospital and five community mental health agencies to improve care transitions for mental health patients. The program hired a Mental Health Navigator and Peer Support Specialist to enhance discharge planning and establish outpatient services. Initial outcomes include a 30% reduction in readmissions, increased engagement in recovery planning, and positive patient experiences and feedback. The success of the program is attributed to improved communication, care coordination, and a focus on patient engagement through trusting relationships and recovery-oriented services.

1. Enhancing Mental Health Care
Transitions: A Recovery-Based Model
Mental Health Care Navigators and Inpatient Psychiatry.
Christina Schwartz, BA Psychology, MHP, Mental Health Navigator
Heather Sievers, RN, MSN, MA Counseling Psychology, PI Advisor

2. Background
 Mental Health Crisis: Patient acuities are worsening and inpatient and
outpatient services are stretched thin. Between 2005-2010, over 50% of
Minnesota’s inpatient mental health beds were closed. Lack of sufficient
inpatient and outpatient mental health services are resulting in an influx of
patients coming to the Emergency Departments to receive Mental Health
care.
 Received a Blue Cross Blue Shield grant to pilot an Enhanced Care Transitions
Project at Abbott Northwestern Hospital in partnership with the Minnesota
Community Healthcare Network (MCHN).
 MCHN includes five outpatient Mental Health Agencies that together provide
an integrated healthcare approach and comprehensive treatment for
individuals living with serious and persistent mental illness and other complex
conditions (including chemical dependency, chronic health conditions, and
socioeconomic challenges): Guild Incorporated, Mental Health Resources,
Resource Inc., Canvas Health, and Touchstone Mental Health.

3. Aim
 The aim of this project is to increase access to community supports for ANW
MH inpatients by developing a collaborative discharge and transition pilot
with MCHN starting April 11, 2016 through the remainder of 2016.
 Opportunities to enhance mental health recovery:
1. Develop mental health interventions that enhance chances of successful recovery
in the outpatient setting and subsequently reduce readmissions.
2. Improve access to community Mental Health resources while a patient is still
hospitalized.
3. Create patient-centered recovery model that promotes early patient and family
engagement in discharge planning.
4. Improve patient advocacy in treatment and demonstrate improvements in patient
experience.
5. Improve communication between inpatient and outpatient resources to assure best
care transitions and follow-up.

4. New Roles hired for Pilot
 Mental Health Navigator (started April 2016):
 A MH professional who partners directly with the patient and care team to
establish essential outpatient services, enhance discharge planning, support
patient-centered recovery initiatives and conduct routine outpatient follow-up
with MCHN contacts and patients.
 Peer Support Specialist (started July 2016):
 A person with a mental health diagnosis who has been in recovery for a minimum
of 1 year and has taken PSS certification.
 Primary role responsibilities are to provide peer support, develop trusting
relationships, act as the patient advocate, participate or run recovery groups,
engage patients more deeply in discharge planning, and provide outpatient follow-
up as needed.

5. ANW-MCHN Pilot Workflow

6. ANW-MCHN Workflow continued…

7. Pilot Outcomes: April 11-Oct 11, 2016

8. Outcomes continued…
 Patient-Centered Recovery Interventions:

9. Readmission Results:
*Note:
29 of 92
pilot
patients
were
homeless

10. Challenges:
 Private insurance: Patient’s aren’t eligible for case management services
 Only 1 MH navigator and 1 PSS covering all adult units and providing
outpatient services
 Original plan to have 3 Transitional Meetings: Goal Setting, Discharge Planning
and Day of Discharge with care team but unable to accommodate as program
grows
 Program has not spread to child/adolescent areas yet (most agencies are
adult-focused)
 Lack of adequate housing resources: 8 year delay in housing services in MN;
get sent to crisis housing or shelter; Homeless Assessment required first, but
only occurs after 14 stays at a homeless shelter. (Note: If a patient goes to a
chemical dependency treatment facility, that counts as housing and drops
their severity on the waiting list)
 Hard to show full impact of our work only after 7 months. Need more time.

11. Overview of Program Successes: Why it works
 “Individuals living with serious mental illness are often difficult to engage in
ongoing treatment, with high dropout rates. Poor engagement may lead to
worse clinical outcomes, with symptom relapse and rehospitalization.”
(Dixon, Holoshitz, and Nossel, 2016).
 Patient Engagement is the key to successful outcomes: Our program
emphasizes the following elements of care:
1. Trusting Relationships: Consistency and continuity of care; strong inpatient and
outpatient support systems, demonstrations of caring and commitment
2. Recovery-focused: Reestablish hope and empowerment of the individual to reach
recovery and life success; emphasis on strengths, clear goals
3. Patient-Centered: Early engagement and autonomy; respect for an individual’s
personal goals and wishes

12. Why our program is working:
 Our Program Interventions are geared at Patient Engagement.
 New Roles and Relationships:
1. Peer Support Specialist: Patient advocacy, trusting relationship, hope for recovery,
crisis intervention, friendship and peer engagement; inpatient and outpatient
support; changing unit culture via a patient-centered recovery model, milieu
management
2. Mental Health Navigator: bridge between inpatient and outpatient recovery;
essential to streamlining transitions into the community; able to see patient in ED
to reduce readmissions; inpatient and outpatient support; able to track patients in
outpatient environment to help Allina understand patient outcomes
3. MCHN Agencies: a network of highly integrated, patient-centered organizations
that also believe in the recovery model, onsite visits and care established prior to
discharge, early follow-up post-discharge, hands-on care in the “real world”,
diverse outpatient treatment opportunities; attend follow-up appointments with
patients as needed

13. Why our program is working, cont…
Improved Communication and streamlined Transition of Care:
1. Onsite Visits or Conference Calls
2. Coordination of Care: Able to work more directly with outpatient resources that better
understand the system and can support us in setting up the best outpatient services
based on the patient’s needs.
3. Open exchange of Communication: Community Hub, MCHN ROI lasts 5 years;
transmission of records; Navigator able to assist with medication or care challenges
after discharge
4. Close-the-Loop Calls (includes patient when possible)
Other Tools:
1. Recovery Plan: Goal setting and personal engagement in decision-making;
understanding support systems and plans for recovery and crisis intervention after
discharge
2. Community Outreach Plan: Maintains continuity of care; easy method for contacting
outpatient providers; supports work of social workers in early discharge planning for
subsequent admissions. If patient readmitted or ED visit, able to notify agency contact
immediately to help intervene early
3. Patient Experience Interviews (prior to and after discharge)
4. Data Tracking: Flowsheet, Google Docs

14. Patient Experience
 “I feel confident that I will not have to come back to the hospital because I
will have more structure at home.”
 “This was a much more positive experience than my last hospitalizations,
thank you so much.”
 “I feel a lot more confident after working with you [Mental Health Navigator]
and getting hooked up with my new agency (MHR).”
 “Treatment was very individualized, everyone took time to help meet my
needs.”
 “Very positive experience, optimistic about resources, best hospitalization
I’ve ever had.”
 “Loved the groups and learning about new coping skills, and loved creating
my recovery plan”
 “Worked with Christina on triggers and coping skills. It feels like I got the help
I needed, and I feel good this time about going home”
 “This went so much better than last time and I feel confident going home.”

15. REFERENCES
 Dixon, L.B., Holoshitz, Y., and Nossel, I. (2016, February). Treatment
engagement of individuals experiencing mental illness: Review and update.
World Psychiatry, 15(1): 13-20. doi: 10.1002/wps.20306.
 Kreyenbuhl, J., Nossel, I.R., Dixon, L.B. (2009). Disengagement from mental
health treatment among individuals with schizophrenia and strategies for
facilitating connections to care: A review of the literature. Schizophrenia
Bulletin,35:696‐703. doi: 10.1093/schbull/sbp046
 Le Boutillier, C., Leamy, M., Bird, V.J., et al. (2011). What does recovery
mean in practice? A qualitative analysis of international recovery‐oriented
practice guidance. Psychiatry Services, 62:1470‐1476. doi:
10.1176/appi.ps.001312011
 Slade, M., Amering, M., Farkas, M. et al. (2014). Uses and abuses of recovery:
Implementing recovery‐oriented practices in mental health systems. World
Psychiatry, 3:12‐20. doi: 10.1002/wps.20084