C. Edward Coffey, M.D. Henry Ford Health System Detroit, MI
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Neuroanatomy of Behavior
Pursuing Perfect Depression Care:A Model for Eliminating Suicide and Transforming Mental HealthcareC. Edward Coffey, M.D.Henry Ford Health SystemDetroit, MIBLUES BUSTERSGood morning everyone
Thank you Dr. X for that very kind introduction.
I am honored by this award, but as I hope to make clear during my presentation, I share this award with all the great teams of individuals with whom Ive had the great pleasure to collaborate throughout my career.
Indeed, its the people ones fellow travelers that make the journey fun and worthwhile.Pursuing Perfect Depression Care:Outline of PresentationCase PresentationA Health Care System in ShamblesA Roadmap for Transformation The IOM Chasm ReportA Model for Transformation HFHS Behavioral Health ServicesFrom Perfect Care to Perfect HealthBLUES BUSTERSThe health care system in this country is in shambles. It pains me to say this, given that I am a part of that system, and given that I am generally a glass is half full kind of guy.
Does anyone here disagree with the premise that we have serious problems with health care in this country? Not too many
But just to reinforce the point, Ill review a clinical case with you, and share some thoughts from others about our health care system in the US.
But there is good news in my presentation today. First of all, there is a roadmap to help us find our way out of this mess Ill describe that roadmap for you. And second, we have an example of a health care system that has used this roadmap to begin transforming itself into a fundamentally different and dramatically better system.
BLUES BUSTERSLet me tell you about a case.
1/01: Mr. B was a 57 y/o divorced (5/00) male pharmacist presents with recurrent MDD, OCD, Alcohol abuse. Rx with Prozac, psychotherapy (what kind who knows??!!)5/01, 7/01: suicide attempts, episodic alcohol abuse11/01: CABG, Prozac to Celexa12/01: Wife returns weapons, pt misses appt, denies SI 2 days later, next day kills himself with GSW to head
Pursuing Perfect Depression Care:The Current System is BrokenIn its current form, habits, and environment, the health care system is incapable of giving Americans the health care they want and deserve The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.
BLUES BUSTERSIronically, in the same year that our patient died, the IOM issued its second report on health care in this country.
2nd IOM report (~Jan 2001) first report focused on medical errors (1999)
The Chasm Report concluded that Pursuing Perfect Depression Care:There Are No ToyotasThe current US system produces exactly what it was designed to highly variable care, widespread failures to implement best practices, and inability to change patterns of practice.
Molly Joel CoyeHealth Affairs, 2001BLUES BUSTERSOthers have echoed similar concerns.Pursuing Perfect Depression Care:Business as Usual Will Not WorkThe current system is in shambles a patchwork relic the result of disjointed reforms and policies that cannot be fixed by traditional reform measures.
BLUES BUSTERSIn April 2002, President Bush established the Presidents New Freedom Commission on Mental Health Care, with a charge of improving that care.
The APA, under the leadership of then President Paul Applebaum, seized the opportunity to provide input into that process and issued its own report (authored by a Blue Ribbon task force led by Steve Sharfstein) entitled A Vision for the Mental Health System.
These reports echoed many of the same themes heard in the Chasm Report, viz that:Mental health is essential to overall healthPt centerednessEvidenced-basedAnticipate needs early screeningEquityTransparency and communication, focus on IT
Pursuing Perfect Depression Care:The Institue of Medicine Chasm ReportSix Dimensions of Perfect CareSafeEffectivePatient centeredTimelyEfficientEquitableBLUES BUSTERSSo, what would perfect care look like
I guess its a bit like the famous definition of pornography you know it when you see it.
Pursuing Perfect Depression Care: A Roadmap for Health Care Transformation10 Rules for Perfect CareCare = relationshipsCare is customizedCare is patient centeredShare knowledgeManage by factMake safety a system priorityEmbrace transparencyAnticipate patient needsContinually reduce wasteProfessionals cooperateBLUES BUSTERSTo its great credit, and to our great fortune, the Chasm Report did not stop with a list of criticisms. It went on to suggest how we might try to remedy the problems.
The report recognized that health care is a highly complex system, and suggested that we focus on 10 rules of health care to transform the system.Visits vs. relationshipsVariability vs. customizationProvider- vs. patient-centeredInfo is a record vs. info is freely sharedDecision making based on training & experience vs. evidenceSafety a provider vs. system responsibilitySecrecy is necessary vs. transparencySystem reacts vs. anticipatesCost reduction is sought vs. continuously decreasedProfessional roles vs. cooperation among all providersPursuing Perfect Depression Care:The Perfect Depression Care InitiativeGoal: Develop a system of perfect care in 2 yearsCompetitive Application Process Coordinated by IHI3000 applications downloaded~300 applications submitted 200125 semifinalists12 finalistsHenry Ford Medical Group Depression Care and Prostate Cancer CareBLUES BUSTERSPursuing Perfect Depression Care:Why Perfection?If 99.9% accuracy is good enough 2 million records will be lost by IRS12 babies will be given to wrong parents18,322 pieces of mail will be mishandled in the next hour2 landings at Detroit Airport will be unsafe todayBLUES BUSTERSHenry Ford Health System
BLUES BUSTERSDescribe BHSClinicalEducationResearch
2 Hospitals9 Clinics419 Employees$55M GPREducation ProgramsResearch ProgramsA system within a systemPursuing Perfect HealthHFHS Behavioral Health ServicesBLUES BUSTERSDescribe BHSClinicalEducationResearchPursuing Perfect Depression Care:HFHS Behavioral Health Services
BLUES BUSTERSDescribe BHSClinicalEducationResearchPursuing Perfect Depression Care:Why Depression?
BLUES BUSTERSPursuing Perfect Depression Care:The Perfect Depression Care InitiativeForm a team, and create a name and logoMap our care processes and identify high leverage OFIs (Planned Care Model)Set specific perfection goals and manage by factEnsure the voice of the customer in care design (the Consumer Advisory Board)Develop and implement rapid tests of change (PDCA Cycles)Continuous learningCelebrate our successesBLUES BUSTERSBLUES BUSTERSWhy We Make What We MakeHenry Ford Behavioral Health as a System of CareHow We ImproveHow We Make What We Make
Plan to Improve(Themes)Improve accessImprove/enhance treatmentImprove ITImprove support services (for better care, better management)Design, RedesignPlanned Care ModelCognitive Behavior TherapyMedication safetyCare PathsTreatment planning processOpen access, DIGMAWebsite, Patient Registry, Home Health PageCustomer KnowledgeHow they judge quality and why?VisionWe will work with you to achieve perfect care, always respecting your individual wants and needs.CustomersPatientsFamiliesReferral sourcesCommunityEmployeesTraineesResearch scientistsHFHSEmployersOther payersSuppliers/vendorsCommunity NeedLife and vitalityRevenueMore jobsLower health care costsHealthier societyModel of superior careOutputsTherapeutic environmentPlan for patient servicesJobs and work environmentDiagnosesPharmacotherapyECTPsychotherapy(Group & Individual)EducationFamily programsInformation/reportsSuppliersStaffHFHSCommunity resourcesPatientsFamiliesEmployersInsurers/other payersVendorsInputsSymptomsHealth care historyExpectationsKnowledgeSkillsAttitudesSupport ProcessesLeadingManagingPlanningBudgetingImprovingBuilding Customer KnowledgeMeasuring PerformanceMarketingTransferring InformationRecruitingRewardingHiringTrainingRecognizingEvaluatingListeningIntegrationCore ProcessesPreventFollow upTreatAssessProvide AccessPreventBLUES BUSTERSSafe Care: Eliminate inpatient falls & med errorsEffective Care:Patient-Centered Care: 100% of patients will be completely satisfied with their careTimely Care: 100% complete satisfactionEfficient Care: 100% complete satisfactionEquitable Care: 100% complete satisfactionPursuing Perfect Depression Care:The Perfect Depression Care Initiative Eliminate suicidesBLUES BUSTERSGoal: Eliminate inpatient fallsStrategies: Risk assessment protocol, Environmental assessment, Risk management database (RadicaLogic)Goal: Eliminate medication errorsStrategies: Increase detection (ADE Trigger Tool), Perfect the verbal order process, Risk management database (RadicaLogic)
BLUES BUSTERSPlanned Care ModelImproved OutcomesHealth System
Health Care OrganizationCommunity
Resources andPoliciesSelf-ManagementSupportDeliverySystemDesignDecisionSupportClinicalInformation SystemsProductiveInteractionsInformed,ActivatedPatientPrepared,ProactivePractice TeamPatient-Centered, Timely, Efficient, and EquitableSafe, Evidence-Based, and CoordinatedBLUES BUSTERSSuicides per 100,000 HMO Patients1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013Suicides per 100,000Expected suicide rate for patients with an active mood disorder (21X)Expected rate for euthymic patients with mood disorder (4-10X)Number of suicides per 100,000 Michigan general populationNumber of suicides per 100,000 HAP-HFMG patients05010015020025021
Pursuing Perfect Depression Care:Perfect Care in Real TimeBLUES BUSTERS
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Pursuing Perfect Depression Care:Perfect Care