A Statewide Collaborative to Improve Timely Mental Health Follow-up for Medicaid Patients After Hospitalization

Providing timely follow-up care after hospitalization reduces readmissions and improves patient outcomes, yet rates for follow-up within seven days of discharge are relatively low.

The authors implemented and evaluated a statewide collaborative (formed in 2018) to improve health outcomes for Ohio's Medicaid population, including a focus on timely follow-up after hospitalization for mental illness within seven days. Interventions (initiated in 2019) included developing new clinical services, completing follow-up phone calls after discharge, reserving dedicated appointment slots for hospital follow-up visits, expanding staffing, initiating collaborative care, convening predischarge planning groups, promoting warm handoffs, and using telehealth. A longitudinal analysis using binomial regression was conducted to retrospectively evaluate quarterly Medicaid claims and eligibility data from 2019 through 2023 to assess for improvement in the percentage of persons discharged who had timely follow-up after hospitalization. To compare annual changes observed for the statewide collaborative with national trends, changes were compared with publicly available data from the National Committee for Quality Assurance (NCQA).

The number of eligible discharges totaled 9,041 across the statewide collaborative from 2019 through 2023. The available data demonstrated improvement in timely follow-up after hospitalization for mental illness, from 47.9% in 2019 to 57.0% in 2023 (quarterly median 51.8%, for 2019-2023). In binomial regression, there was a highly significant increase in the probability of follow-up over time (p < 0.001). Compared with publicly available national payer data from NCQA, the collaborative had higher rates of follow-up (by 7.5 percentage points across the study period, p = 0.015), and the difference in trends over time was statistically significant (difference in slope = 2.15 percentage points per year, p = 0.01).

A statewide learning collaborative was associated with an increased percentage of Medicaid beneficiaries receiving timely follow-up after hospitalization for mental illness.