Overview

This project aimed to improve follow-up care for Integrated Behavioral Health (IBH) patients being discharged from the hospital through Health Systems Genogram, an electronic, provider-facing clinical tool designed to improve coordination between clinicians by allowing clinicians to easily identify patterns of behavior or hereditary tendencies.

Organization Name

Department of Family and Community Medicine, Saint Louis University

Organization Type

• Academic Medical Center
• Community hospital
• FQHC

National/Policy Context

• Even though integrated behavioral health (BH) aims to improve gaps in the delivery of mental health services in the US, a common language for physicians with various levels of training remains necessary.
• A genogram would allow physicians across specializations to quickly and efficiently gain an understanding of a patient’s psychosocial and family systems contexts.

Local/Organizational Context

• The lack of a concrete tool around parameters of communication between medical and BH clinicians with different levels of training is inefficient, requiring clinicians to document information gathered through a family assessment in various places.
• There was a strong need need to improve transition from inpatient to outpatient primary care in underserved communities.

Patient Population Served and Payor Information

• Hospital patients transitioning to primary care practices
• Underserved populations in both urban and rural settings
• Patients with health literacy and access to care challenges

Leadership

• Max Zubatsky, PhD, Assistant Professor of Medical Family Therapy Program, Department of Family and Community Medicine, Saint Louis University

Funding

• The study received support from a Primary Care Training and Enhancement grant through Health Resources Services and Administration (HRSA-16-042).

Research + Planning

• Prior to beginning the project, there was a communication assessment between medical and other clinicians.
• The project’s initial aim was to utilize BH graduate students to assess the systemic and social factors that impact patients’ likelihood to follow through with outpatient appointments after discharge from the hospital.

Tools or Products Developed

• Health Systems Genogram: a clinician tool created allow for the an efficient and comprehensive family assessment, including the important systemic and social factors that impact patients’ likelihood of engaging with medical follow-up.
• Information collected includes medical and mental health conditions, relationship patterns, cultural themes, employment history, appointment scheduling, medical management, transportation, and the members of the family system involved in care.
• Connections are drawn between members in the genogram and responses around healthcare management and decision making. See example here.

Training

• BH attendings and residents were trained via 30-minute didactic lectures on how to use the genogram in practice.
• One BH supervisor would train each BH using two patient cases in the hospital using the genogram.  The BH learner would then conduct a genogram assessment with the supervisor shadowing. Each genogram assessment in the hospital takes between 15-20 minutes.  

Tech Involved

• Electronic medical record

Team Members Involved

• Mental Health Provider
• Physicians

Workflow Steps

• Within 48 hours of hospital discharge, providers fill out the Health Systems Genogram on paper with the patient’s input.
• The genogram is then presented both verbally and on-paper to the inpatient medical team. The genogram is scanned into the outpatient EHR for the outpatient primary care team.
• When a patient presents for outpatient follow-up after hospitalization, clinicians are able to review the the patient’s genogram in order to understand the patient’s psychosocial and family contexts. This allows clinicians to prepare for more comprehensive follow-up, anticipating and therefore more ably addressing the patient’s barriers to health.
  • Example: if a patient is known to have had a complicated course of diabetes mellitus, the team’s diabetes educator could be brought in to speak with the patient during the visit.

Budget Details

• Time developing a genogram template through the electronic system

Where We Are

• The project is ongoing. Over 40 assessments have been conducted in the hospital.

Outcomes

• Hospital readmissions: the intervention reduces the risk of hospital readmissions for patients with chronic health conditions.
• Provider communication/collaboration: this intervention allowed for increased collaboration and communication among physicians, BH providers, and other healthcare professionals.
• Ease of care transition: the intervention made transfer of this information from inpatient to outpatient teams more efficient and effective.

Benefits

• The project allowed for improved outcomes, including decreased hospital readmissions, improved provider communication/collaboration, and increased ease of care transition from the outpatient to inpatient setting.
• Filling out these assessments for patients have improved residents’ awareness of impact of social determinants of health in patients’ care.

Sources

• Input from Dr. Zubatsky
• Zubatsky M, Brieler J. A Health Systems Genogram for Improving Hospital
  Transitions to Primary Care. Ann Fam Med. 2018 Nov;16(6):566. doi:
  10.1370/afm.2318. PubMed PMID: 30420376; PubMed Central PMCID: PMC6231937.