Grady Health System, Atlanta GA. Upstream Crisis Intervention

Transcription

1 2014 Changes EMS Leadership Conference Augusta, Ga Grady Health System, Atlanta GA. Upstream Crisis Intervention 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 Vision Grady Health System will become the leading public academic healthcare system in the United States

2 Upstream Crisis Intervention Innovative way to reduce ER transports through alternate pathways; nurse advice, and alternate destinations. How Grady EMS implemented a community paramedic program for patients with mental illness and/or substance abuse conditions.

3 Learning objectives for this presentation: Opportunities to reduce the use of ALS ambulances in the response and transport to requests Alternate pathways for patients, an alternative to the traditional ER transport destination. Alternative to the traditional reactionary EMS response, community based home visits before the call. Develop relationships with agencies and facilities to enhance patient outcomes. Patient case reviews to determine root-cause dependency on and promote reliance on more appropriate resources.

4 Underlying Issues of Top 88 Frequent callers 2012

5 Video

6 Grady EMS Atlanta, Ga. In 2013, Grady EMS encountered 7,900 psychiatric related calls based on the paramedic s Provider Impression of Anxiety, Behavioral Disorder, Depression, and Psychiatric Emergency. In 2013, 6,410 (5.9%) calls triaged through NAEMD category 25 (psychiatric / suicide attempt). Ninety (90) percent of psychiatric patients encountered by Grady EMS and transported to GHS did not require admission Expense ER-the ED average loss per patient was -$401 EMS average loss per ambulance transport was- $109.

7 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. The Grady EMS Crisis Unit program was designed to move this discharge disposition upstream.

8 ALTERNATE PATHWAY Alternate Pathway 2010 Ambulances Transport to Neighborhood Health Centers 2011 BLS Tiered Response 2012 Nurse Advice Call Center 2013 Upstream Crisis Intervention Unit/GCAL * , , , ,

9 Phases Prior to Pilot: Officer forms and law enforcement Partnership with BHL Phase 1: Pilot Team Phase 2: GCAL referrals from EMS crews Phase 3: MOU to transfer 911 callers to G.C.A.L. Phase 4: Implemented ADP for crisis pts Phase 5: Primary responding unit Phase 6: Unscheduled and Scheduled home visits Phase 7: Doubled staffing in August 2013

10 Crisis and Access Management Services

11 Georgia Crisis and Access Line (GCAL) GCAL currently serves as a crisis call center for the entire state of Georgia. All calls are answered by a licensed mental health professional to provide crisis intervention services and linkage to an appropriate service provider based on the level of acuity. GCAL provides crisis intervention services via the call center 24/7/365 to individuals seeking assistance with behavioral health related crisis. Since 2003, the call center has received over 259 million calls. In 2013, GCAL answered 200,000 calls, about 800 per day.

12 Mobile Crisis Response Services (MCRS) The BHL MCRS teams currently serve Regions 3 and 5. This covers an expanded metro Atlanta area as well as the southeastern quarter of the state, including the Savannah, Dublin, Brunswick, and Waycross areas. Other MCRS exist in other areas of the state. The MCRS team provides mobile crisis services in the community 24/7/365 through a team consisting of a licensed mental health clinician and a non-licensed mental health paraprofessional. MCRS team members are strategically placed throughout coverage area to ensure that individuals are seen within a timely manner. Region 3 average response time February 2014: 46 minutes.

13 Mobile Crisis Response Services (MCRS) Interventions include de-escalation, crisis evaluation, and appropriate service linkage. Linkages may include appointments, referral to community services, or hospitalization as a last resort. Goals include an overall decrease in the number of hospitalizations and presentations to emergency departments. In Region 3, 60% of individuals are diverted from ER and hospitalization. Of those hospitalized, many are referred directly to mental health facilities and bypass the ER.

14 Officer forms and law enforcement Grady EMS met with an Atlanta Police Department (APD) Deputy Chief and other senior leaders at the Zone levels Grady EMS adopted language from the APD policy so both agencies would have a common understanding, terminology, and defined process Grady EMS and APD reviewed the policy with all staff Grady EMS provides copies of 1013 and Officer forms

15 Crisis Program Began 40-hours week Crew configuration Vehicle needs Dual response De-escalation results

16 Phase 2: GCAL referrals directly from EMS crews Phase 3 MOU to transfer first party callers directly to G.C.A.L.

17 Phase 4 Implemented ADP Transported to in-patient psychiatric facilities Paramedics contacted EMS Medical Director or EMS Fellow for screening and approval. Assured safety of the program, regarding appropriate patient dispositions, without under- triage of patients with emergency conditions.

18 Phase 5 Primary responding unit Altered response to eliminate ambulance response with team. Based on NAEMD 25 A and B

19 Grady EMS Upstream Crisis Intervention Unit Alternate Destination Program Paramedic Medical Evaluation BHL Mental Health Evaluation Refusal; GCAL Card, Outpatient Appointment Ambulance or 7070 Transport to ED Transport to in-patient psychiatric or substance abuse facility Direct Admit transport to in-patient bed located at a hospital with an ED: Unscheduled or Scheduled home visit Non-911 initiated response EMS Supervisor Notification Courtesy ride to pharmacy, shelter, etc. BHL confirms bed acceptance EMS Medical Director Notification for ADP Approval Dr. Yancey: xxxxxxxx Dr. Bloom: xxxxxxxx PET TEAM DIRECT # AMC-N: xxxxxxxxxxx AMC-S: xxxxxxxxxxx Investigate opportunities to decrease 911 use. (Referral to ACT. Medication, pharmacy, housing, or other needs)

20 Phase 6 Unscheduled and Scheduled home visits 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 patients from misusing EMS and ER

21 Phase 6 Unscheduled and Scheduled home visits What was offered pts Courtesy ride to obtain medications Courtesy ride to appointments Scheduled appointments Coordinated pharmacy efforts Checked medications bottles for compliance and expiration dates Follow-up to assure patient is going to appointment on day of visit and 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 Crisis Team a cell phone for pts to make direct contact Reconnect pts with their providers; medical or mental health Family members provided GCAL cards

22 Part 6 Continued Unscheduled and Scheduled home visits Provide family members support with referrals and Crisis Team cell number Connect pts with ACT team and case managers Courtesy rides to shelter or secondary residence Courtesy rides to a caregiver or better support system Remove pts from location that is escalating and providing courtesy rides 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) Courtesy rides to appointment with financial counselors WHAT EVER IT TAKES to help the mental health patient Many cases of pts calling 911 more than 5 times per month going to zero after home visits.

23 Upstream Crisis Intervention 2013 January 1 December 31 Totals Total 25 EMD psych calls 24/ Calls transferred to GCAL- no 911 response 175 Total psych unit responses 1250 Refusals 276 Cancellations after onscene 202 Transported in psych unit to ADP 66 Transported in psych unit to ED 307 Transports by ambulance to ED- violent 327 Calls medical and not psych in nature 94 Total mitigated from 911 ambulances 1026 Total mitigated from ED 517 Unscheduled home visits attempts 151 Unscheduled home visits- patient contact 59

24 Case Studies

25 Home Visit Case Study 1 36 year old female moved to response area, history of bipolar disorder and chronic depression. In one month, 911 called 8 times. Mobile crisis unit engaged patient. Connected with GCAL and arranged a mental health appointment. Mobile Crisis Unit followed up with a home visit to discover patient missed appointment due to transportation issues. Mobile Crisis Unit rescheduled appointment, and transported to and from appointment. Since home visits, patient has not called 911 for mental health complaints.

26 Home Visit Case Study 2 57 y.o. with history of schizophrenia, bipolar, hypertension, drug abuse. 911 contacted 12 times within 3 months. Identified lack of insurance was barrier. Provided transportation to Grady financial services and pt applied for Medicare/Medicaid. Provided transportation to outpatient psychiatric clinic. With completed application, pt was able to obtain immediate appointment. To date patient has not contacted 911 and is now receiving benefits.

27 Home Visit Case Study 3 71 y.o. history of depression 911 contacted 9 times in one month. Added to home visit list During home visit, crew identified multiple prescriptions from various pharmacies, hampering compliance. Mobile crisis crew transferred all prescriptions to delivery pharmacy. Since home visit, patient has not contacted 911.

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