Discharging Patients in Collaborative Care
About Discharging Patients
Effective discharge planning in collaborative care begins at enrollment. From the outset, care managers inform patients that this treatment model is brief yet impactful, typically lasting 4-6 months. Throughout their participation, patients are empowered with self-management techniques, coached in new skills, and supported as they practice managing their symptoms. Prior to discharge, patients collaborate with their care manager to develop a concrete plan for ongoing symptom management and support. This approach ensures patients feel confident in maintaining their behavioral health long after they complete the program.
Patients can be discharged from collaborative care in three main ways: when they are ready for discharge (the most preferred method), when they need a higher level of care, or due to lack of engagement.
(1) Patient is ready for discharge
Determining if a patient is ready for discharge can be both literal and figurative. If a patient explicitly states they are ready, it's important to discuss this with them and honor their wishes. Additionally, if a patient has met all their goals and is feeling better, this indicates readiness for discharge. This improvement can be communicated verbally during individual check-ins or indicated through measurement feedback in the Mirah Platform. Consistent positive feedback reports over several months are a good sign that a patient may be ready for discharge.
Regardless of the circumstances, it's crucial to have a solid discharge plan in place to ensure the patient has the necessary information and resources for future support. Discharge planning should occur simultaneously with ongoing care, allowing support to remain in place while the patient transitions away from collaborative care treatment.
Remember that discharge planning is a collaborative process. Include the patient's voice and involve the entire care team to ensure everyone is on the same page. This approach allows for necessary follow-ups and is particularly helpful for the PCP during subsequent appointments.
Recommended resource: Self-Management Plan Template for CoCM Discharge Planning
(2) Discharging to a higher level of care
In the early stages of a collaborative care program, it's common for primary care providers to refer their most concerning patients. This can lead to care managers working with patients who may be too acute for the program. While all patients can benefit from collaborative care, it's important for care managers to maintain balanced caseloads to ensure appropriate services and prevent burnout. The recommended caseload distribution is 80% patients with mild to moderate symptoms and 20% with more severe symptoms.
It's entirely appropriate to use collaborative care as a bridge to more intensive treatment. This could involve referrals to individual therapy, psychiatry, or more specialized settings such as residential programs, Intensive Outpatient Programs, Partial Hospital Programs, or Inpatient Hospital Programs. In these cases, the care manager should communicate the plan to the patient/caregivers and care team, ensure everyone is informed, and make the necessary referrals. The care manager may also need to check in with the family and provide updates to relevant team members.
(3) Discharging due to lack of engagement
While discharging a patient due to low engagement is not ideal, it's important to recognize that sometimes patients are not ready, and that's okay. Follow your practice's policies regarding patient outreach. If you're unsure about the policy, consult your supervisor or Collaborative Care lead. After unsuccessful attempts to reach out according to your policy, inform the referring PCP and discharge the patient. Remember, patients can always be referred back to the program when they're ready.
For more detailed information on discharge planning and mental health, you can refer to this resource.