Reducing Psychiatric Readmissions

Transcription

1 Reducing Psychiatric Readmissions Leslie S Zun, MD, MBA, FAAEM Chairman and Professor Department of Emergency Medicine Professor, Department of Psychiatry Chicago Medical School Mount Sinai Hospital Chicago, Illinois

2 Objectives To identify patients types who are at risk for readmission To address issues in the Emergency Department to prevent readmissions To address issues in the inpatient setting to reduce readmissions

3 40%-50% of Psychiatric Patients are Readmitted within 1 Year

4 Risk Factors for Psychiatric Readmission Machado,V, et al: Psychiatric readmission: an integrative review of the literature. Int Nursing Rev 2012; Low level of schooling Younger age Schizophrenia Personality disorders Psychoactive substances Males Time for complete recovery # of prior hospitalizations Condition of living Admitted prior year Receiving disability No discharge plan for PCP

5 Recommend increased community based psychiatric services Factors Associated with Psych Hospitalization from ED Hamilton, JE, et al: Factors associated with the likelihood of hospitalization following emergency department visits for behavioral health conditions. Accad Emer Med 20016;23: Factors Disorders Increased age Arrival by EMS Longer LOS Uninsured Lack of community based mental health Schizophrenia Suicidal Affective disorders Dementia Personality disorders Impulse control

6 Patient Subsets Suicide admissions Elderly with substance use disorder Personality disorder Prior psych admission Unemployed Receives social benefits

7 Patient Subsets Elderly with Substance Use Disorders Risk for readmission Prior hospitalization for substance use disorder Psychiatric comorbidities Poisoning Adverse drug reactions Falls Recommendation Focus intervention on women with psychiatric illness and accident risk

8 Patient Subsets Involuntary Admissions Lower patient satisfaction Living with others Lower economic status Country of origin Poor global functioning

9 Patient Subsets Pediatric Inpatient Admission Blader, JC: Symptom, family, and service predictors of children s psychiatric rehospitalization within one year of discharge. J Am Acad Child Adolsc Psych 2004; 43: Usually within 90 days Factors Conduct problems Harsh parental discipline Disengaged parents Parents stress level

10 Patient Subsets - Emergency Department COMPLIANCE OF MEDICATIONS BY PATIENTS PRESENTING TO THE ED S. Yen 1, L. Downey 2, L. Zun 3, and T. Burke 4 There were a total of 214 participants in the study 106 medical and 108 were psychiatric Took on average between 2 to 6 meds/day There was no significant difference between the two groups Psychiatric pts. were more likely to get admitted (50%) than medical pts. (31%)

11 Before Patient Arrives at the Emergency Department Review of frequent readmissions from the ED By patient By diagnoses By ED MD Action plan to reduce ED/hospital use Social worker in ED

12 Inappropriate Admissions from the ED Legal and liability of sending patients home Secondary utilizes such as police, group homes, nursing homes and families Send to ED to resolve issues Lack of appropriate assessment Difficulty in contacting provider Need for collateral information Problem with obtaining old medical records Lack of outpatient resources Housing Medication Care givers

13 ED Treatment Tendency to keep patient in the ED with limited, if any, treatment Not medicated or in therapy Alternative Involve psychiatry in the patient care (Consultation & Liaison service) Role of telepsychiatry Begin other therapeutic interventions Medicate in the ED

14 ED Treatment Interventions Brief intervention Fleishmann: Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries Bull WHO 2008;86: International study of 8 EDS Brief intervention and enhanced follow up Reduced number of deaths Enhanced Intervention Rotherham-Borus: The 18-month impact of an emergency room intervention for adolescent female suicide attempters J Consulting & Clinical Psych 2000;68: month study of female Hispanic patients Soap opera video, family therapy, and staff training Reduced suicide re-attempts and ideation

15 ED Treatment Interventions Rapid response Greenfield: A rapid-response outpatient model for reducing hospitalization rates among suicidal adolescents Psych Services 2002;53: Suicidal adolescents in a pediatric ED Rapid response team psychiatrist & RN with assessment, meds & community follow-up Lower hospitalization rate Psychiatric service provided in ED Damas, C, et al: Economic impact of crisis intervention in emergency psychiatry: a naturalist stud. Eur Psych 2005;20: Psychotherapeutic approach Counseling of patient and family Reduced voluntary hospitalizations 19.5% and increased outpatient consultations 14.4%

16 In ED Crisis Intervention in UK Damas, C, et al: Economic impact of crisis intervention in emergency psychiatry: a naturalist stud. Eur Psych 2005;20: Psychiatric service provided in ED Psychotherapeutic approach to considering the crisis an event Counseling of patient and family Before and after cost and reduction of hospitalizations Reduced voluntary hospitalizations 19.5% and increased outpatient consultations 14.4%

17 Medication Re-start prior meds Start new medications Psychiatry via telepsychiatry Assistance from C and L service Medications to start in ED Antidepressants Antipsychotics Mood stabilizers Benzodiazepines

18 ED Discharge Set up follow up appointments Sharma, G, et al: Outpatient follow-up visits and 30 day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease. Arch Intern Med 2010:170: ,746 COPD patients, 66.9% had PCP follow up Patients who follow up visit reduced the risk of an ED visit and readmission Begin case management Gil, M, et al: Impact of a combined pharmacist and social worker program to reduce hospital readmission J Mang Care Pharm 2013;19: Involve social work and pharmacy Set up home health services Med reconciliation and F/U phone calls Communicate with PCP Pang, PS, et al: Patients with acute heart failure in the emergency department: do they all need to be admitted? J Cardiac Fail 2012;18: Hand off to primary care

19 For Discharged Patients ED s Role Clear, detailed discharge plans tailored to patient, family, clinicians, case managers and payers Teach self-care Improved instructions and instruction process Patient read back Encourage self-management Telehealth technology to monitor at home ED physician/nurse/social worker phone calls Assign a patient navigator

20 Does the Psych Patient Need to Be Admitted Admission criteria Telepsychiatry Suicide risk assessment Diversion programs

21 Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted? Not always an easy decision Use of admission criteria or guidelines for many conditions Risk to self, Risk to others, Unable to care for self Improved assessment for admission Telepsychiatry Diversion programs Suicide risk assessment Alternatives to inpatient stay

22 Admission Criteria Lyons, JS, et l: Predicting psychiatric emergency admissions and hospital outcome. Ed Care 1997;35: Decision support tool Criteria Suicide potential Danger to others Severity of symptoms Predicted 73% of the admissions

23 Crisis Triage Rating Scale Bengelsdorf, H, et al: A crisis triage rating scale: brief dispositional assessment of patients at risk for hospitalization. J Nerv Mental Disease 1984;172: Scores three categories 1-5 A. Dangerousness B. Support system C. Ability to cooperative Scoring 9 or more outpatient/crisis intervention 8 or less - admit

24 Admission Determination Severity Description Suicidal Disposition Need for Hospitalizatio n Stable Low level Functional, works Had medical or psych stressor None Outpatient No Mild Outpatient OBS Moderate Decompensated agitated Moderate Psych consultation Yes or OBS Severe Severe decompensation High Inpatient care Yes

25 Mobile Crisis Units and Telepsychiatry Mobile Crisis Units Jugo, M, Smout, M, Bannister, J: A comparison in hospitalization rates between a community based mobile emergency service and a hospital-based emergency service. Aust N Z Psychiatry 2001;36: Comparison of mobile unit to ED admission rate ED admitted 3x more than mobile units Telepsychiatry Shre, JH, Hilty, DM, Yellowlees, P: Emergency management guidelines for telepsychiatry. Gen Hosp Psych 2007:29: High provider and patient satisfaction Wide variety of diagnosis, age and complaints Consultations, diagnostic assessment, medication management, family and patient psychotherapy

26 Determination of Suicide Risk Myths All patients who want to harm themselves or others need admission Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated All teenagers with suicide gestures or thoughts need admission Maybe not

27 Suicide Risk Determination Needs to includes static and dynamic factors, protective elements and means. Suicide risk assessment is a clinical judgement Tools may augment the judgement It is an imprecise science

28 Outpatient Can the Suicidal Patient Go Home Kennedy, SP: Emergency department management of suicidal adolescents. Ann Emerg Med 2004;43: Medical treatment not needed No prior suicidal attempt No actively suicidal Adult in house with good relationship Adult agrees to monitor Adult will move guns and medications Whom to contact for deterioration Follow up arranged Agreement to plan and recommendations

29 Chronically Mentally Ill in Crisis Other Options Emergency Department Mental Health or Community Mental Health Psychiatric Home Care Living Room Crisis Phone Service Crisis Mobile Units Psychiatrist Mental Health Worker Community Service Integrated Services Inpatient Care Crisis Stabilization Unit Observational Care Day hospital Psychiatric Urgent Care

30 30

31 Crisis Oriented Residential Treatment Weisman, GK: Crisis-oriented residential treatment as an alternative to hospitalization. Hosp Commun Psych 1985;36: For acutely distributed chronic patients For acutely decompensated patients that might need acute hospitalization Highly structured Group and individual therapy Therapeutic activities Expectations of appropriate behavior Cost effective

32 Brief Admission Programs Neal, MT: Partial hospitalization. Nur Clin NA 1986:21: Functions Acute treatment Brief intensive therapy Long term supportive re-socialization or rehabilitation Day hospital Usually 5 days a week for 2-3 months Mon-Friday Patient types Not suicidal, homicidal or assaultive? Psychotic patient & substance use disorders

33 Role of Community Mental Health Center Specialized clinics for specific disorders Early intervention and teams Assertive community treatment teams Multidisciplinary approach to intensive services in the community (home or work) Psych, nursing, social work, substance abuse tx, employment Alternative forms of occupational and vocational rehabilitation

34 Day Hospital vs. Crisis Respite Care Sledge, WH, et al: Day Hospital/Crisis care versus inpatient care, Part II: Service utilization and costs. Am J Psych 1996:153: Voluntary patients in need of acute psychiatric care Compared day hospital/crisis respite program to inpatient stay Programs were equally effective Average cost savings of $7,100 per patient

35 Psychiatric Home Health Biala KY: Psychiatric home health: the newest kid on the block. Home Care Provid Jul-Aug;1(4): Psychiatric nurses, social workers, home health aides, and occupational therapists to work at pt s home CMS allows all physicians to sign a Medicare psychiatric plan of care. Results in significant reduction in both hospitalization admission and recidivism rates.

36 Involuntary Out-Patient Commitment Swartz, MS, et al: Can involuntary outpatient commitment reduce hospital recidivism? Am J Psych 1999;156: Compared hospital release to hospital discharge to outpatient commitment 57% fewer hospitalizations 20% fewer hospital days Non-affective psychotic disorders had highest rate 72% reduction

37 Observational Care Appropriate use of OBS units for psychiatric patients Psychosis Suicidal Depressed Anxiety Alcohol and drug intoxication/withdrawal Social situation Requirements Provides adequate stability and containment Availability of consultation liaison service 37

38 Crisis Stabilization Units Breslow, RE, Klinger, BI, Erickson, BJ: Crisis hospitalization on a psychiatric emergency service. Gen Hosp Psych 1983:15: Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs Patient types Schizophrenics Personality disorder Sucidality Substance use disorders 41% of total patients seen

39 Clinical Profile Thinn, DSS, et al: The 23 hour observation unit admissions within the emergency service. Prim Care Companion.2015;17:1-11. Young males Stress related, anxiety, affective spectrum psychotic disorders CGI-S improved Inpatient admission from OBS associated with selfreferral, older, lower GAF scores and < improvement The Clinical Global Impression Severity scale (CGI-S) is a 7- point scale that requires the clinician to rate the severity of the patient's illness at the time of assessment, relative to the clinician's past experience with patients who have the same diagnosis. The Global Assessment of Functioning (GAF) is a numeric scale (1 through 100) to rate subjectively the social, occupational, and psychological functioning of adults, e.g., how well or adaptively one is meeting various problems-in-living..

40 Patient Outcome in Psych OBS Admass, CL, El-lallakh, RS: Patient outcome after treatment in a community based crisis stabilization unit. J Beh Health Ser and Res. 2009;36: Patient outcome in CSU BPRS changed from moderately ill to mildly ill Beck s depression scale improved greatly The Brief Psychiatric Rating Scale (BPRS) is rating scale which a clinician or researcher may use to measure psychiatric symptoms such as depression, anxiety, hallucinations and unusual behavior. The Beck Depression Inventory (BDI) is a 21-item, self-report rating inventory that measures characteristic attitudes and symptoms of depression

41 Regionalization of Acute Psychiatric Care Zeller, S, Calma, N, Stone, A: Effects of regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Em 2014;15:1-6. Prior 30 day period efforts have focused on increasing inpatient beds Alternative is prompt access to treatment Evaluate and treatment patients in a given area and take patients from EDs 30 day period examined all patients from 5 EDs on voluntary holds 144 patients had average boarding time of 1 hour and 48 minutes 24.8% were admitted

42 Sinai CSU Treatment safe/low stimulation milieu to rapidly assess, stabilize and discharge patient Population adults self-preservation & ADLs Capable of decrease pt. boarding time in ED Increase pt. access to psych services/tx Earlier psych consult & meds Increase pt. connection with outpatient services Initiate psych assessment earlier in process

43 Inpatient Issues Use of feedback of psychotherapy Peer mentor program (.89 vs. 1.53) Community mental health (20% lower) Assertiveness Community Treatment (58% lower) Home visits Discharge readiness assessment Medication alternatives like long acting IM meds Multifaceted inpatient psychiatric approach

44 Inpatient Issues Weekly readmission rounds Readmission focus in discharge rounds Teach back method Outpatient follow up in 3 days Family engagement focus Post discharge phone calls Improving community linkages

45 Pediatric Inpatient Reduction Focus on initial hospital stay Complex treatment needs of conduct disorders Improve child-parent relations

46 Enhanced Integrative Strategies Unutzer J et al: The Collaborative Care Model: an approach for integrating physical and mental health care in Medicaid health homes. Health Home Information Resource Center, Center for Health Care Strategies, Inc. May 2013 Medical home Embedded medical, substance use & psychiatric services in clinics Condition education Family involvement in care Patient communications Frequent communications Phone, web or text Supportive services Peer mentor Community healthcare worker Patient navigator Medications Medication reconciliation Depot meds Assertive Community Treatment (ACT) Homeless SMI population Multidisciplinary team Non-traditional services NAMI Help phone lines

47 Interventions that Work Vigod, SN, et; al: Transitional interventions to reduce early psychiatric readmission in adults: A systematic review. Br J Psych 2013; 202: Review of 15 studies without overlapping interventions Pre and post discharge patient psychoeducation Structured needs assessment Medication reconciliation/education Transition managers Inpatient to outpatient communication Outpatient follow-up Regular consultations Attendance at activities

48 Take Home Point Emergency Department Look for ED deflection programs such as mobile crisis teams and law enforcement for those that do not need an ED Some patients can go home after ED evaluation with or without telepsychiatry Consider admission options such as observation, short stay or crisis respite Inpatient Need for aftercare communication, instructions, appts Follow up with the patient Use long acting medication

49 Contact Information Leslie Zun, MD Mount Sinai Hospital 1501 S California Chicago, IL zunl@sinai.org