Best Practices for Continuity of Care During and After Care Coordination

Rula leaves the decision of whether or not to resume care with your patient after a higher level of care (HLOC) referral up to you as their provider. In some cases, this means you'll temporarily suspend seeing the patient while they engage in a higher level of care support, such as PHP and IOP. In other cases, you should absolutely continue treating the patient while they engage in an adjunct service, such as a support group or group therapy. 

Discharge Planning

Discharge planning from any intensive outpatient or partial hospitalization program is a mandatory procedure as per the Mental Healthcare Act of 2017. It can be a patient-friendly and highly practical approach to guiding patients and improving their quality of life and mental health in the community. Proper discharge planning can improve the outcome and prognosis of individuals diagnosed with behavioral health needs.

Continuing Psychiatry

Patients should be made aware of any plans for discharge/withdrawal of care by their psychiatric provider. Be sure to document any discussion of termination of care within the patient’s chart in AMD. If you’re a prescriber referring a patient to HLOC, it’s important your patient also has enough medication to last through their treatment and continuity of care for medication management as they step down. This also won't hurt your patient retention because you are still involved in your patient's journey. Any patients who are presenting with SI/HI with intent/planning are recommended to be referred out of Rula to in-person For additional guidance regarding your discharge protocol, please see HERE.

Documenting Patient Outcomes

Care coordinators will enter a blank note documenting the outcome of any submitted request for an adjunct or higher level of care request in the patient’s chart. 

Best practices for providers to ensure clinical recommendations are being/have been addressed and your patient has responded to outreach from Care Coordination:

• Be sure to advise your patient that Care Coordinators will be reaching out to them regarding your recommendation
• Make sure you’re documenting the conversation you’re having with your patient regarding your recommendation for adjunct or HLOC services within their progress notes
• If/when referring to IOP or PHP: 
  • Make sure you’re documenting any potential planning once the individual is discharged/completes the program
  • When terminating care due to HLOC needs, consider potential risks associated with your patient being discharged without care. If this is a factor for you, there is always the potential for them to be rematched with another provider who specializes in their needs.
  • Discuss and document reasons why you might be ending care after their completion so your patient is aware you’ll no longer be their provider once the program is completed.
    • Consider meeting with your patient until they have scheduled their first appointment with a new provider. As their treating clinician, you can decide this at your discretion.

• If you’re continuing care with your patient, make sure to regularly assess their symptoms and/or mood for any potential risks. For more information about utilizing measurement-informed care (MIC) in your everyday practice, please reference Rula’s help center articles HERE.

Communication from Care Coordination

The care coordination team may reach out to you throughout the referral process for the following reasons. Therefore, we ask that you maintain engagement until the referral is complete:

• Discuss your recommendation for further clarification of your request.
• Inform you of any limitations in locating your specific request and, therefore, seek your support in recommending alternative options. 

The care coordination team will communicate with you and your patient via email and/or phone call. Once the referral is processed and outreach efforts are complete, the care coordinator will leave a care coordination note and/or a blank note in the patient’s chart that includes:

• Details of all actions taken.
• The overall outcome of the submitted request.

Please check the patient’s chart and your email to be apprised of all communication regarding your HLOC request.

Kaiser SoCA Specific Patients

All HLOC referrals are facilitated by the patient's designated Kaiser liaison, and the care coordination team is not provided with a timeline for completing the referral or when the patient can expect Kaiser outreach. 

Kaiser will conduct an internal assessment to determine if the patient meets medical necessity for the recommended level of care. Kaiser will conduct an internal assessment to determine if the patient meets medical necessity for the recommended level of care. It is possible that the referral will not be processed for the following reasons:

• Patient is deemed inappropriate for the recommended level of care, and Kaiser will provide the reason(s) for its determination.
• Patient declines treatment.
• Patient does not respond to Kaiser’s outreach attempts. 

Updated June 21, 2024 21:16