After Care Follow Up (AFU) | CTBHP Providers

After a hospital stay, it is important to provide ongoing care and support to individuals through After Care Follow Up (AFU). CT BHP is dedicated to assisting both the individual and their loved ones by connecting them to outpatient resources and collaborating with providers to create a tailored discharge plan. CT BHP aims to support providers in facilitating a smooth transition back to daily life, whether it’s returning home, going back to work, or resuming school. Comprehensive person-centered discharge planning also enables providers to closely monitor progress, address any obstacles, promote medication adherence, and ensure overall well-being.

Why is this Important?	How is it Measured?
AFU Service Types	Provider Support and Intervention

Why is this Important?

Receiving appropriate post-treatment care has been proven to reduce the chances of being readmitted to a hospital. Additionally, ensuring the continuity of care increases the likelihood that individuals will engage in follow-up visits and help providers detect any post–hospitalization medication problems, leading to better outcomes.

How is it Measured?

This measure assesses the percentage of discharges, with a primary diagnosis of mental illness receiving a follow-up visit appointment within 7 (Rate 1) or 30 days (Rate 2) of Discharge. Members included in the measure are those with hospitalization with a primary diagnosis of mental illness or intentional self-harm, Medicaid members age 6 years+ on the date of discharge, and must be continuously enrolled from the date of discharge through 30 days, with no gap.

For more information on specific and/or statewide Follow-up After Hospitalization (FUH) data, please reach out to your local Regional Network Manager.

AFU Service Types

Medication Management with a Psychiatrist/APRN
Individual visits in the home (including telephone visits), office, or behavioral health setting following program specifications
Electroconvulsive Therapy (ECT)
Intensive Outpatient Program (IOP) or Partial Hospitalization Program (PHP)
Mental Health and/or Substance Use Assessments, Screenings, Treatment Planning
Community-Based Wrap-Around and/or Day Treatment Services

Provider Support and Intervention

Provider Best Practices

Schedule an appointment before discharging a Member from a mental health hospitalization.
Discuss the Member’s treatment plan with them at discharge.
Begin discharge planning at admission.
Arrange a transition visit for the Member at the time of discharge. Transitional services address the many barriers that prevent Members from successfully seeking and receiving care.
Link the Member to a Community Support Program (CSP) provider while the Member is in the inpatient unit. Members should be connected to a CSP in their region, regardless of the location of the inpatient admission.
Encourage the Member to sign a Release of Information form so that you can communicate with other providers who share in the care of your Member.
Work with the Member’s natural supports to assist in their aftercare.

Provider Intervention