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Federal Register / Vol. 86, No. 147 / Wednesday, August 4, 2021 / Rules and Regulations
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combination of SUD, dementia, or behavioral health disorders, populations that also benefit from timely follow-up care.
Furthermore, compared to the criteria for provider type in the current FUH
measure, the FAPH measure does not limit the provider type for the follow-up visit if it is billed with a diagnosis of mental illness or SUD. During the measures testing, the most frequent provider types for the FAPH measure were family or general practice physicians, internal medicine physicians, nurse practitioners, and physician assistants. The technical expert panel TEP convened by our contractor agreed that these provider types should be credited by the measure for treating mental illness and SUD and confirmed that this is aligned with integrated care models that aim to treat the whole patient. The TEP further noted that in areas where there are shortages of mental health or SUD
clinicians, other types of providers are often the only choice for follow-up treatment. Allowing visits to these types of providers to count towards the numerator allows the measure to capture the rates of appropriate followup care more accurately in areas with provider shortages.
Performance on the FAPH measure indicates that follow-up rates for patients hospitalized with mental illness or SUD are less than optimal and that room for improvement is ample.
The clinical benefits of timely follow-up care after hospitalization, including reduced risk of readmission and improved adherence to medication, are well-documented in the published literature.125 126 127 128 129 130 131
125 Tong, L., Arnold, T., Yang, J., Tian, X., Erdmann, C., & Esposito, T. 2018. The association between outpatient follow-up visits and all-cause non-elective 30-day readmissions: A retrospective observational cohort study. PloS one, 137, e0200691. https doi.org/10.1371/
journal.pone.0200691.
126 Terman, S. W., Reeves, M. J., Skolarus, L. E., & Burke, J. F. 2018. Association Between Early Outpatient Visits and Readmissions After Ischemic Stroke. Circulation. Cardiovascular quality and outcomes, 114, e004024. https doi.org/10.1161/
CIRCOUTCOMES.117.004024.
127 First Outpatient Follow-Up After Psychiatric Hospitalization: Does One Size Fit All? 2014.
Psychiatric Services, 666, 364372. https
doi.org/10.1176/appi.ps.201400081.
128 Terman, S. W., Reeves, M. J., Skolarus, L. E., & Burke, J. F. 2018. Association Between Early Outpatient Visits and Readmissions After Ischemic Stroke. Circulation. Cardiovascular quality and outcomes, 114, e004024. https doi.org/10.1161/
CIRCOUTCOMES.117.004024.
129 Jackson, C., Shahsahebi, M., Wedlake, T., &
DuBard, C. A. 2015. Timeliness of outpatient follow-up: An evidence-based approach for planning after hospital discharge. Annals of family medicine, 132, 115122. https doi.org/10.1370/
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Behavioral health patients in particular have a number of risk factors that underscore the need for timely follow-up and continuity of care:
Behavioral health patients have higher baseline hospitalization rates, higher hospital readmission rates, and higher health care costs as compared with the general population of patients.132 133
Among patients with serious mental illness, 90 percent have comorbid clinical conditions such as hypertension, cardiovascular disease, hyperlipidemia, or diabetes.134 Among patients hospitalized for general medical conditions, those who also have a mental illness are 28 percent more likely to be readmitted within 30 days than their counterparts without a psychiatric comorbidity.135 The high prevalence of clinical comorbidities among behavioral health patients, combined with the compounding effect of mental illness on patients with general medical conditions, suggests that behavioral health patients are uniquely vulnerable and supports the intent of the measure to increase followup after hospitalization.
In addition, clinical practice guidelines stress the importance of continuity of care between settings for patients with mental illness and SUD.
For the treatment of SUD patients, the 2010 guidelines of the American Psychiatric Association APA state: It is important to intensify the monitoring for substance use during periods when the patient is at a high risk of relapsing, including during the early stages of treatment, times of transition to less 130 Hernandez, A. F., Greiner, M. A., Fonarow, G.
C., Hammill, B. G., Heidenreich, P. A., Yancy, C.
W., Peterson, E. D., & Curtis, L. H. 2010.
Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA, 30317, 17161722. https doi.org/10.1001/
jama.2010.533.
131 Nadereh Pourat, Xiao Chen, Shang-Hua Wu and Anna C. Davis. Timely Outpatient Follow-up Is Associated with Fewer Hospital Readmissions among Patients with Behavioral Health Conditions.
The Journal of the American Board of Family Medicine. May 2019, 32 3 353361; DOI: https
doi.org/10.3122/jabfm.2019.03.180244.
132 Germack, H.D., et al. 2019, January.
Association of comorbid serious mental illness diagnosis with 30-day medical and surgical readmissions. JAMA Psychiatry.
133 First Outpatient Follow-Up After Psychiatric Hospitalization: Does One Size Fit All? 2014.
Psychiatric Services, 666, 364372. https
doi.org/10.1176/appi.ps.201400081.
134 First Outpatient Follow-Up After Psychiatric Hospitalization: Does One Size Fit All? 2014.
Psychiatric Services, 666, 364372. https
doi.org/10.1176/appi.ps.201400081.
135 Benjenk, I., & Chen, J. 2018. Effective mental health interventions to reduce hospital readmission rates: A systematic review. Journal of hospital management and health policy, 2, 45. https
doi.org/10.21037/jhmhp.2018.08.05.

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intensive levels of care, and the first year after active treatment has ceased. 136 This statement is accompanied by a grade of I, which indicates the highest level of APA
endorsement: recommended with substantial clinical evidence.
Evidence supports that outpatient follow-up care and interventions after hospital discharges are associated with a decreased risk of readmissions for patients with mental illness.137 138 IPFs can influence rates of follow-up care for patients hospitalized for mental illness or SUD. Three studies reported that with certain interventionssuch as predischarge transition interviews, appointment reminder letters or reminder phone calls, meetings with outpatient clinicians before discharge, and meetings with inpatient staff familiar to patients at the first postdischarge appointmentfacilities achieved 30-day follow-up rates of 88
percent or more.139 140 141 This is substantially higher than the national rate of about 52 percent observed in the current FUH measure for Medicare FFS
discharges between July 1, 2016, and June 30, 2017.142 Medicare FFS data from July 1, 2016, to June 30, 2017, show the national 7-day follow-up rate to be 35.5 percent and the 30-day rate to be 61.0 percent. These data reveal wide variation in follow-up rates across facilities, with a 16.9 percent absolute difference between the 25th and 75th 136 American Psychiatric Association. Practice guideline for the treatment of patients with substance use disorders. 2010. http
psychiatryonline.org/pb/assets/raw/sitewide/
practice_guidelines/guidelines/substanceuse.pdf.
137 Kurdyak P, Vigod SN, Newman A, Giannakeas V, Mulsant BH, Stukel T. Impact of Physician Follow-Up Care on Psychiatric Readmission Rates in a Population-Based Sample of Patients With Schizophrenia. Psychiatr Serv. 2018;691:6168.
doi: 10.1176/appi.ps.201600507.
138 Marcus SC, Chuang CC, Ng-Mak DS, Olfson M.
Outpatient follow-up care and risk of hospital readmission in schizophrenia and bipolar disorder.
Psychiatr Serv. 2017;6812:12391246. doi:
10.1176/appi.ps.201600498.
139 Batscha C, McDevitt J, Weiden P, Dancy B.
The effect of an inpatient transition intervention on attendance at the first appointment post discharge from a psychiatric hospitalization. J Am Psychiatr Nurses Assoc. 2011;175:330338. doi: 10.1177/
1078390311417307.
140 Agarin T, Okorafor E, Kailasam V, et al.
Comparing kept appointment rates when calls are made by physicians versus behavior health technicians in inner city hospital: literature review and cost considerations. Community Ment Health J.
2015;513:300304. doi: 10.1007/s10597014
9812-x.
141 Olfson M, Mechanic D, Boyer CA, Hansell S.
Linking inpatients with schizophrenia to outpatient care. Psychiatr Serv. 1998;497:911917. doi:
10.1176/ps.49.7.911. Quality AFHRA. 2017
National Healthcare Quality and Disparities Report.
Rockville, MD: Services USDoHaH; 2018.
142 https data.cms.gov/provider-data/archiveddata/hospitals.

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