INNOVATIONS IN BEHAVIORAL HEALTH · Results: Behavioral Health Crisis clinicians evaluated ~100...
Transcript of INNOVATIONS IN BEHAVIORAL HEALTH · Results: Behavioral Health Crisis clinicians evaluated ~100...
Webinar Agenda
Welcome
Danielle Lazar, Senior Research Associate, Urgent Matters
Behavioral Health and Detoxification: Meeting Demand for Services
Michael A. Turturro MD, FACEP, Associate Professor of Emergency Medicine, University of Pittsburgh School of Medicine, Chief of Emergency Services, UPMC-Mercy, Pittsburgh, PA
Upstream Crisis Intervention
Michael Coleman, MPA, Director of EMS Operations at Grady Health Systems, Atlanta, GA
Behavioral Health and
Detoxification:
Meeting Demand for
Services
Michael A. Turturro MD, FACEP
Associate Professor of Emergency Medicine
University of Pittsburgh School of Medicine
Chief of Emergency Services, UPMC-Mercy
Pittsburgh, PA
UPMC-Mercy 433 Inpatient Beds
34 Behavioral Health Beds
18 Medically-managed Inpatient Detox Beds
Level I Trauma Center, Urban
73,000 ED visits/year
29 General Beds
2 Bed Trauma Resuscitation Bay
5 Bed Fast Track
17 Bed CDU
Behavioral Health Intake Evaluation Area (ERC) –
Capacity 13
Background
Nationally: decrease in inpatient and long-term
behavioral health bed availability
Efforts to increase care in the community have
not filled this void
Funding decreasing for behavioral health and
addiction services
Acute med-surg hospitals caught in the middle,
often ill-equipped
Utilization of community resources often not
optimized
Background
ED volumes increasing
Lack of specialized services to EDs
Risk of adverse events
Regulatory barriers to care
The Setup
2002-2008: Closure of inpatient behavioral
health units in 5 hospitals within Allegheny
County
December 2008: 350 bed state run regional long
term behavioral health facility closed by
Commonwealth of PA
Discharged into less restrictive, community-based
settings "to reduce reliance on institutional care and
improve access to home and community-based
services for Pennsylvanians living with mental
illness”
The Setup
January 2009-June 2012
ED volume increased 22%
Visits for behavioral health/detox increased 325%
2009: 2173 visits
2012: 6689 visits
Admission rate increased 95% with no increase in
capacity
Nearly 80% of visits could be managed in a less
restrictive setting than inpatient
The Setup
End Result
Delays in patient evaluation
Boarding of admitted behavioral health patients in
the ED, medical floors
Exacerbation of hospital crowding
Hospital expenditures on staff to “babysit” patients
Staff dissatisfaction
Intervention
Organization of stakeholders within the hospital
and community
Emergency Medicine
Psychiatry
Addiction Medicine
Hospitalists
Nursing
Hospital Administration/Support Staff
Goals
Optimize safe alternatives to hospitalization
Streamline inpatient care to facilitate capacity
Specific Tactics: Aug 2012- Jan 2013
Partnership with competing behavioral health
facilities
Manage volume regionally rather in silos
No-hassle transfers facilitated
Secure outpatient appointments
Within 1 week of ED or inpatient stay
Referrals to partial and respite programs
Specific Tactics: Aug 2012- Jan 2013
Partnership with community-based crisis
intervention center (ReSolve)
Conversion of ERC RN positions to crisis clinician
positions
Serve as first point of contact for behavioral health
patients 16 hrs/day
Structured suicide risk assessment
Link to community resources (housing, food banks,
transport services, etc.)
Goal: patient remain in the community whenever
possible
Specific Tactics: Aug 2012- Jan 2013
Conversion of ERC RN position to detox
clinician position
Dedicated space in the ED for evaluations 16
hours/day
Structured referrals to ambulatory and inpatient
detoxification and rehabilitation programs
Evaluate in parallel to ED evaluation rather than
sequential
Specific Tactics: Aug 2012- Jan 2013
Inpatient
Utilization review training: ERC and inpatient
behavioral health staff
Post discharge planning on hospital day 1
Training of inpatient staff in detoxification
assessment and treatment
Transition from inpatient to outpatient treatment of
opioid detoxification
Transition from phenobarbital taper to symptom-
triggered treatment for ETOH withdrawal (inpatient
LOS reduction tactic)
Results: Detoxification Detox RNs evaluated >300 pts/month
10-fold increased in outpatient referrals from 1st quarter
CY 2012 to 1st quarter CY 2013
Decrease in detox 30-day recidivism from 17% to 10%
Mean wait time for detox evaluation
May 2012: 68 minutes
May 2013: 18 minutes
Mean ED length of stay for admitted patients
May 2012: 17 hours
May 2013: 9 hours
Mean ED length of stay for discharged patients
May 2012: 9 hours
May 2013: 6 hours
Results: Behavioral Health
Crisis clinicians evaluated ~100 pts/month
81% increase in transfers to available beds from 1st
quarter CY 2012 to 1st quarter CY 2013
160% increase in referrals to non-hospital programs
from 1st quarter CY 2012 to 1st quarter CY 2013
Mean wait time for behavioral health evaluation
May 2012: 67 minutes
May 2013: 11 minutes
ED length of stay for admitted patients
May 2012: 34 hours
May 2013: 11 hours
Costs/Benefits
Conversion of RN to crisis clinician position =
33% saving in salary/benefits
Decrease in RN time spent managing behavioral
health/detox patients
Decrease in expenditures on sitters house-wide
Facilitation of outpatient care decrease in ED
visits
Change in care delivery decreased need for
staffing sustainability
Further Opportunities
Overnight ReSolve/Detox RN staffing
Enhancing psychiatry coverage (ED and
hospital)
On-site sobering center for intoxicated patients
Development of a State-wide bed tracking
system
Modeled after Maryland
Co-sponsored by PaACEP and PaPS
PA Medical Society Resolution Adopted
Advice
Get all stakeholders involved early and often
Investigate, then engage all community
resources
Eliminate competitive barriers/silos
Grady EMS Grady Health System, Atlanta GA.
Upstream Crisis Intervention
Vision Grady Health System will become the leading public academic healthcare
system in the United States
Michael Colman, MPA, NRP, Director of EMS Operations at Grady Health Systems
Arthur H. Yancey, II, MD, MPH, FACEP, Associate Professor Department of Emergency
Medicine Emory University School of Medicine and Grady EMS Medical Director
Grady EMS Atlanta Ga.
• In 2012 Grady EMS encountered 5,807 psychiatric related calls based on the paramedic’s Provider Impression of Anxiety, Behavioral Disorder, Depression, and Psychiatric Emergency.
• Ninety (90) percent of psychiatric patients encountered by Grady EMS did not require admission
• Expense
– ER-the ED average loss per patient was -$401
– EMS average loss per ambulance transport was- $109.
Grady Health System
• Fifty (50) percent of psychiatric patients registered at Grady’s ED were ultimately discharged with a referral and/or appointment for outpatient care.
• This program design to move this discharge disposition ‘upstream’ into the EMS field
Background
• 3 week pilot program began in Jan 2013
• Involved: EMS leadership, senior hospital leadership to the CEO level, Medical Direction from EMS, physician partnership from psychiatry, partnership with BHL to provide a social worker with expertise in mental health and a background of working on a mobile crisis unit.
• Pilot never ended.
Grady Health System
Grady EMS Prehospital Paramedicine
Clinical Alternate Destination Program
Alternate Pathway
Decrease Attrition and Paramedic burnout
Decrease Overtime
Decrease Unit Hour Utilization (UHU)
Decrease need for additional 911-ALS ambulances
* Prorated projected number for 2013
** These calls now fall under Nurse Advice.
*** When Nurse Advice projections met, BLS will decrease
BLS Tiered
Response
2011
2012- 153
2013**-30
Non-Emergency
Transportation
911-ALS Response
Nurse Advice Call
Center
2012
Ambulances Transport to
Neighborhood Health
2010
Crisis Intervention
Unit
2013
2012- 3,932
2013-12,000* ***
2012- 1,513
2013- 8,000* 2013- 884*
2012 Decrease in 911-ALS Responses
5,598
Projected Annual Decrease in 911-ALS Responses
18,914
Projected Annual Savings to Grady Health System
$1,084,020
Phases
• Prior to Pilot (Officer forms and law enforcement, 08/2012)
• Part 1 (the Pilot Team, 01/2013)
• Part 2: (GCAL referrals directly from EMS crews, 02/2013)
• Part 3 (MOU to transfer first party callers directly to G.C.A.L.)
• Part 4 (Expansion of ADP, 04/2013)
• Part 5 (Sole responding unit, 04/2013)
• Part 6 (Alteration of hours, 06/2013)
• Part 7 (Unscheduled and Scheduled home visits, 08/2013)
• Part 8 (doubled staffing to 80-hours per week, 08/2013)
Prior to Pilot
(Officer forms and law enforcement, 08/2012)
• Grady EMS met with an Atlanta Police Department (APD) Deputy Chief and other senior leaders at the Zone levels
• Grady EMS reviewed the Officer Forms and APD policy in reference to Peace Officers taking a person into custody for mental health concerns
• Grady EMS adopted language from the APD policy to create a mirror so both agencies would have a common understanding of the process
• Grady EMS and APD reviewed the policy with all staff because even though the policies existed, they had not been executed in many years
Part 1
(the Pilot Team, 01/2013) • Grady EMS SUV co-respond with an ambulance.
• Triaged through the National Academy of Emergency Medical Dispatch NAEMD category 25 (psychiatric / suicide attempt),
• Crew consisted of: Grady EMS paramedic, a Grady Behavioral Heath Licensed Professional Counselor (LPC), and a BHL Licensed Clinical Social Worker (LCSW) or LPC from their mobile crisis unit. – Additionally, on some shifts a psychiatry PGY3 from Morehouse.
Part 2:
(GCAL referrals directly from EMS crews,02/2013)
• Training session to provide overview of Georgia Crisis and Access Line (GCAL).
• Provided medics with business cards
• Medics called number and advised the clinician it was a referral and handed phone to pt.
• Used when crisis team not available.
Part 3 (MOU to transfer first party callers to G.C.A.L.)
• Grady EMS finalized an MOU with GCAL on February 16, 2013.
• Implemented in April 2013.
• Allowed our 911 call center (PSAP) to directly transfer specific psychiatric triaged calls (NAEMD 25-omega) to GCAL.
• Grady’s 911 center has transferred 70 calls to GCAL.
• No ambulance responded
Part 4
(Expansion to offer ADP, 04/2013) • The crisis team transported patients to in-
patient psychiatric facilities
• Medics contacted EMS Medical Director or EMS Fellow for screening and approval.
– Assure safety of the program, regarding appropriate patient dispositions from the field, without under triage of patients with emergency conditions who were not dispositioned to the ED.
Grady EMS Upstream Crisis Intervention Unit Alternate Destination Program
Ambulance or 7070
Transport to ED
Courtesy ride to
pharmacy, shelter,
etc.
Paramedic Medical Evaluation
BHL Mental Health Evaluation
Transport to in-patient
psychiatric or substance abuse
facility
Refusal; GCAL
Card, Outpatient
Appointment
Direct Admit transport
to in-patient bed
located at a hospital
with an ED:
EMS Supervisor
Notification BHL confirms bed acceptance
EMS Medical Director
Notification for ADP Approval
Dr. Yancey 404-985-7248
Dr. Bloom 404-686-1000
PET TEAM DIRECT #
AMC-N: 404-265-1200
AMC-S: 404-266-2645
Unscheduled or Scheduled
home visit
Non-911 initiated response
Investigate opportunities
to decrease 911 use.
(Referral to ACT.
Medication, pharmacy,
housing, or other needs)
Part 5
(Sole responding unit, 04/2013) • Altered response to eliminate ambulance
response with team.
Part 7
(Unscheduled and Scheduled home visits, 08/2013)
• Integration of a Community Paramedic program for pts with mental health issues
• Pts identified through high user lists
• QA department screened charts (EMS/ER) to determine optimal cases.
• Prevent from misusing EMS and ER
Part 7 (Unscheduled and Scheduled home visits, 08/2013)
• What was offered pts – Transport to obtain medications
– Transport to appointments
– Scheduled appointments
– Coordinated pharmacy efforts
– Checked medications bottles for compliance
– Follow-up to assure they are going to appointment or medications were obtained.
– In-service training to family members to administer prescribed injections of psych meds.
– Engaged family members to call when pt arrives.
– Provided team with a cell phone for pts to make direct contact
– Reconnect pts with their providers; medical or mental health
– Given family members GCAL cards
Part 7 Continued (Unscheduled and Scheduled home visits, 08/2013)
– Provide family members support with referral option and team cell number
– Connect pts with ACT team and case managers
– Transport pts to shelter or secondary residence
– Transport pts to a caregiver or better support system
– Remove pts from location that is escalating and transporting to a secondary location.
– Worked to place a homeless pt into a nursing home
– Worked to secure temporary housing
– Worked with case management at hospital to investigate eligibility to receive benefits (Medicaid or other discount)
– Transport to hospital to appointment with financial counseling
– WHAT EVER IT TAKES to help the pt with mental health
– Many cases of pts calling 911 more than 5 times per month going to zero after home visits.
Data
Calls transferred to GCAL- no 911 response- 70
911 responses by psych unit- 01/14-11/30/13 1124
Unscheduled home visits attempts/phone contact 116
Unscheduled home visits- patient contact 34
Refusal, no transport- 248
Cancellations, no pt found-EMS not needed- 183
Transported in psych unit to ADP- 53
Transported in psych unit to ED- 260
Psych Transports by ambulance to ED 79
Calls medical and not psych in nature 88