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Addressing the missing link in long-term patient care: The transition home

For those patients discharged from a long-term care facility back into the community, provider teams must work to ensure continuity of care is preserved and that patients receive the same quality and level of care in their homes as they did while in an institutional setting

Since the pandemic began more than 18 months ago, the healthcare industry has experienced a notable shift in where and how post-acute care is delivered to patients. After early Covid-19 outbreaks occurred in nursing homes, patients – particularly the elderly – and their families have shown an increased preference for home-based care rather than institutional settings such as nursing homes, skilled nursing facilities, and assisted living facilities.

For those patients discharged from a long-term care facility back into the community, provider teams must work to ensure continuity of care is preserved and that patients receive the same quality and level of care in their homes as they did while in an institutional setting – particularly as these long-term care providers face census challenges in the industry-wide shift to home-based care. To streamline the discharge process, minimize 30-day hospital readmissions, and optimize patient outcomes, long-term care facilities can offer patients access to post-discharge behavioral health services.

Behavioral health care services are often overlooked following a patient’s discharge home. However, readmission rates for patients with behavioral health comorbidities have been shown to be nearly twice those of patients without a behavioral health comorbidity – and 20% of people over the age of 55 have some form of mental health condition, and that percentage is higher in institutional care settings. Consider this scenario: a hip replacement patient encounters mental health struggles – for example, depression – during a stay at a long-term care facility. Once the patient has rehabilitated from surgery and it is time for the discharge back into the community, the facility’s discharge planning team, family members, or the patient may acknowledge the need for additional behavioral health services to help guarantee a safe and successful recovery in the home. To reduce gaps in patient care, long-term care facilities must make behavioral services – specifically, those available via telehealth – available to patients immediately upon the discharge home. A comprehensive care model integrating therapy with medication management will strengthen the support system for the patient, ultimately resulting in higher successful transitions rates. These services benefit both patients and providers, as well as other cross-continuum stakeholders.

Telehealth increases access to behavioral healthcare services

As discharge planning teams in long-term care facilities work diligently to secure a patient’s post-discharge health services, it can be challenging to locate a behavioral health provider – such as a psychiatrist – accepting new patients, or a provider that is close to home and easily accessible for the patient. Many long-term care facilities are currently understaffed – 99% of nursing homes and 96% of assisted living communities have reported current workforce challenges – and do not have the time nor resources to discover and secure accessible behavioral health services in a timely manner for patients following discharge. Assuming long-term care facility discharge planners do identify an available behavioral health provider, the patient will presumably need to wait several weeks, months, or even one year for an available appointment. A future shortage of geropsychologists is anticipated, and unfortunately the shortage of general mental health professionals is already here; for every 100,000 people in the U.S., there are only 30 psychologists and 15.6 psychiatrists. Patients frequently face detrimental gaps in their care – particularly their mental health care – which can prevent a patient’s successful recovery at home.

Leveraging telehealth for behavioral health care, patients can receive necessary services immediately; in most cases, within a week of their discharge. Eliminating the need for transportation to appointments behavioral telehealth services also reduce the burden on patients and their caregivers. This is an important benefit as, depending on the reason for a patient’s stay in a long-term care facility, some individuals may have decreased functionality or mobility and be unable to secure transportation to a behavioral health provider. Also, for patients requiring home health care services following their inpatient stay at a long-term care facility, they may be hesitant to leave the home on a regular basis or for too long a duration while receiving such services. Behavioral telehealth services eliminate these potentially dangerous barriers to care.

Achieving care continuity through behavioral telehealth

Behavioral telehealth benefits not only facilities, but also patients. Through behavioral telehealth services, patients receive continuity of care; care managers follow up with them to schedule an appointment shortly after discharge, and patients receive the same quality of care, and cadence of care, within their own homes as they would if they were still residing in a long-term care facility. For recently discharged patients, a seamless handoff, “soft landing,” and smooth transition back into the community can potentially be the difference between a successful at-home recovery and an unnecessary hospital admission or costly, avoidable emergency room  visit.

Behavioral telehealth services are more widely accessible and easier to coordinate than traditional face-to-face behavioral health visits, and so may reduce the burden on long-term care facility discharge planning teams as they seek post-discharge care for the patient. Behavioral telehealth also offers providers an “umbilical cord” or safety net to ensure patients have access to mental health support on an as-needed basis from the safety of their own homes. These services can also ease the admissions process or increase referrals; with access to behavioral telehealth at the point of discharge, long-term care facilities have the capabilities to admit a broader array of patients requiring behavioral health services during their stay and upon their return to the community.

Behavioral telehealth and transitions of care 

Post-discharge behavioral health services help provide patients a smooth transition from an institutional care setting to at-home care with minimal to no disruption to the plan, which results in greater clinical stability for the patient and improved outcomes for all involved stakeholders.

Because elderly patients are not likely to utilize mainstream consumer behavioral telehealth offerings by their own volition, there is a critical need for care coordination services offered directly through providers. This approach allows a patient’s cross-continuum care team to provide a consistent, high-touch, warm approach for the patient’s well-being. Ultimately, a coordinated care model enables providers to ensure that patients receive necessary care in a timely manner and do not fall through the cracks between the time of discharge at a long-term care facility and when they arrive home.

Dr. Sherie Friedrich, PsyD, is chief psychology officer at MediTelecare, where she has focused on the growth and development of the Department of Psychology. Dr. Friedrich has worked in psychiatric hospitals, community mental health settings, and in private and group practice, and has also worked as a psychological consultant conducting comprehensive evaluations for state and private institutions. Dr. Friedrich is passionate about leading initiatives toward ambulatory behavioral health care for aging populations. Dr. Friedrich completed her undergraduate studies in Psychology at the University of New Hampshire and received her Doctorate in Clinical Psychology from Antioch University. She completed an APA internship at Albert Einstein College of Medicine in NYC, working with adult patients on a long-term secure psychiatric unit. Additional training experiences include a formal Postdoctoral Fellowship at Seacoast Mental Health Center and a one-year advanced Psychotherapy Fellowship at Boston Psychoanalytic Institute.

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