2107 Title: Home-Based Treatment: Bridging the Gap from Hospital to Home-Based Care Date / Time: Thursday, June 10, 2010 at 02:30 PM - 04:00 PM Type: CONCURRENT Level: INTERMEDIATE Sponsor(s): - Speaker(s): Christine Degan; Susan B. MacDermott Beacon recognizes the increased vulnerability of patients discharging from psychiatric hospitals, the challenges of successful transition to community care, and the risk of recidivism and other negative health outcomes. As a result, Beacon analyzed the reasons patients do not keep post-psychiatric hospital follow-up appointments. Findings revealed that patients who do not have a pre-existing relationship with an outpatient practitioner; but do have a history of treatment, non-adherence, chronic medical illness, and/or lack of stable home environments are the most likely to not keep such appointments. Beacon’s goal was to address these issues, via an innovative home-based treatment program that deploys contracted outpatient practitioners to the patient, rather than expecting at-risk patients to attend their initial post discharge appointments. The program has shown very impressive results to date. This session will discuss how to: 1)  Improve HEDIS 7-Day Follow-Up After Mental Health Hospitalization rate; and 2)  Improve community tenure. The aforementioned goals are accomplished by early identification of post-discharge issues impacting the patient’s ability to keep a scheduled appointment. Issues are identified through active collaborative discharge planning with inpatient treaters, and the provision of a bridge between inpatient and outpatient treatment. The approach of this program is to meet the patient where they are in the recovery process, determine with the treater, the patient's aftercare needs; and then match these needs to a specific outpatient practitioner type. For example: A patient with a depressive disorder, who has co-morbid diabetes, will have an APRN or certified psychiatric nurse provide home-based therapy, as well as health coaching and education. All products Beacon manages [Aged, Blind and Disabled (ABD), Temporary Assistance for Needy Families (TANF), Medicare and commercial] are included in this program. Outcome data is showing that patients with post-hospitalization home visits are demonstrating improved adherence to their discharge plans, including medication adherence, resulting in fewer readmissions and increased community tenure. This session will lead participants through the development of the program and a network of providers, describe the specialized interventions unique to the program, discuss the importance of alignment with case management services, and finally review program outcomes. Case studies will be utilized to illustrate key points. Objectives: Describe the Home-Based Therapy Program so that attendees will be able to describe three (3) factors that led Beacon to justify the need for the program. Describe the design of the Home-Based Therapy Pro­gram operational model, so that attendees will be able to list three (3) of the four (4) essential elements of the program design. Identify aggregate outcome data, so that attendees will be able to describe three (3) key findings of the program. Also present case studies on program impact on high-risk members so attendees will be able to describe three (3) key Characteristics of individuals who benefit most from the program.