Behavioral Health Educational Webinar Series Inpatient Psychiatric Treatment: A Preview

Transcription

1 Behavioral Health Educational Webinar Series Inpatient Psychiatric Treatment: A Preview Dennette Janus, MA, LPC Quality Improvement Specialist Health Services Advisory Group (HSAG) Friday, May 11, 2018

2 Available After the Presentation Slide of Prescription Assistance Resources Certificate of Attendance Resource Sheets Crisis Intervention Behavioral Health (BH) Treatment/Services Substance Abuse Treatment/Services Educational Opportunities Everyday Needs The PowerPoint from today s presentation will be available in approximately one week at 2

3 Online Poll: What Do You Say? How do you rate your knowledge of what inpatient psychiatric treatment looks like right now? a. Very high b. High c. Low d. Very low 3

4 What is HSAG? Funded by the Centers for Medicare & Medicaid Services (CMS) Subcontracted with CMS as a Quality Improvement Organization (QIO) for specific improvement tasks Focus population is Medicare Fee-for-Service (FFS) Part-A, including dual-eligible beneficiaries Largest federal program dedicated to improving health quality at the community level HSAG is the QIO in Arizona, California, Florida, Ohio, and U.S. Virgin Islands Reducing BH readmissions is one of the improvement tasks under the contract Department of Health & Human Services CMS 4

5 Behavioral Health (BH) by the Numbers General BH Information Number one cause (World Health Organization 1 [WHO]) 20% of adults in U.S. National Alliance on Mental Illness 2 (NAMI) 50% of chronic mental illness less than age Readmissions 3 from an inpatient psychiatric stay Approximately 20% readmission rate within 30 days 33% in less than 7 days Most readmissions are to a different facility than the one just discharged from Medical Behavioral 5 1. World Health Organization National Alliance on Mental Illness (NAMI): 3. HSAG Analysis of Medicare FFS Part-A claims for Q Q3 2017

6 HSAG BH Webinars Presented to Date 2017 Series 1. Behavioral Health Basics 2. Understanding Common Disorders 3. De-escalation Techniques 4. Community and Behavioral Health Resources 5. Voluntary vs. Involuntary Evaluation and Treatment 6. Medication and Medical Issues Quarter 1 of 2018 Relationship Alphabet Soup: Understanding Legally Defined Relationships M D P O A These recorded webinars and related materials are available at no-cost at: 7

7 Other HSAG Readmission Reduction Resources 30-day Readmission Audit Tool Template Top 10 Readmission Reduction Interventions Jane s Behavioral Health Experience Patient videos Medication management Adverse drug event (ADE) resources Vetted Arizona and nationwide resource Lists Teach-back resources and information 7 All of this is part of HSAG s ongoing work with PCPs, IPFs, and community stakeholders toward improved care coordination and readmission reduction:

8 Benefits of Knowledge About Inpatient Psychiatric Facilities (IPF) and Treatment Professionals Current referral of patient/client Educating patients/clients/family members for future needs Helps everyone know what to expect Increases confidence: professional, patient, family/loved one Improves empathy for what a person has experienced inpatient 8

9 Benefits of Knowledge About IPF and Treatment (cont.) The person potentially going inpatient Decreases fear/unknowns Increases comfort and trust May be more likely to ask for help when needed Patient can help educate others 9

10 Benefits of Knowledge About IPF and Treatment (cont.) When expectations are different than reality: misunderstandings Conflict and additional stress at receiving facility Poor patient experiences (e.g., feeling misled) Distrust of professionals/system Increase in against-medical-advice (AMA) requests Reluctance to seek help again 10

11 Inpatient Referral Sources Self Walk-in to emergency department (ED) or IPF Crisis line or 911 calls Others Family member Outpatient counselor Crisis mobile team Primary care physician (PCP) Friend Clergy School counselor Concerned citizen 11

12 Typical Process Crisis Made Known Safety Established Rule Outs* BH Assessment/ Intervention Disposition Transfer or Discharge *Considerations like head injury, infection, blood sugar imbalance, substance intoxication are sought to be ruled out before determination that a person needs inpatient behavioral health admission. 12

13 Why Everyone Asks the Same Questions Individual assessment required Doctor Social worker or BH professional Nurse Case manager Pre-hospital Admission Throughout treatment Discharge Post-discharge 13

14 Options for Referral/Disposition Inpatient Voluntary Involuntary Detox * *Not all insurance covers detoxification treatment or treatment at a facility of the patient s choice; there are usually self-pay or community-based options for treatment regardless of insurance coverage. Outpatient Partial hospitalization (PHP) Intensive outpatient (IOP) Traditional outpatient (OP) Community resources and referrals 12-Step Faith-based Everyday needs (food, clothing, shelter, prescriptions) Benefit programs (SSI 1 /SSDI 2 ) Supplemental Security Income 2. Social Security Disability Insurance

15 Options for Referral/Disposition (cont.) With all assessments Education Safety planning Lethal means evaluation Support system involvement 15

16 Criteria for Inpatient Treatment Less restrictive levels of care (LOC) have failed Patient is unable to remain safe in outpatient LOC Unable to reliably contract to be safe Limited or no support system Recommended support/intervention not available within acceptable time frame Danger to self (DTS) Danger to others (DTO) Gravely disabled (GD) 16

17 Factors in Treatment Options/Choices Patient Variables Type of treatment needed Insurance benefits available/financial situation Bed availability Smoking preference Age, gender, health of patient Diagnosis-specific variables Legal status Facility Variables Type of treatment offered Insurance accepted or options for payment Bed availability Smoking policy Age, gender, health of patient Diagnosis-specific variables Legal status 17

18 Most Facilities Have Restrictions: Release of information (ROI) Callers 1 Visitors 1 Release of records Wardrobe Belts Shoelaces Heels Hoodies Profanity Any item representing Drugs/alcohol/violence Personal items Blankets/pillows Stuffed animals Therapy/assistance dogs 2 Medication Over-the-counter products Toiletries (e.g., hair dryer) 1. Parent/guardians authorize anyone having contact with a minor patient 2. Refer to: (revised 2015) 18

19 A Note on Medications The doctors who approve the patient s admission to an IPF: Monitors and adjusts medications while the patient is there Must also approve all medicines given to the patient while in the facility Includes what the patient takes/ uses unsupervised at home (e.g., prescription or over-the-counter products) Medical marijuana is not allowed in IPFs 19

20 Most Facilities Have Restrictions Smoking * Cigarettes Lighters/matches E-cigs/vaping Patches/gum Sharing Schedule Technology * Cell phones Laptops/notebooks ipads Ear buds Headphones Anything with batteries 20 *Very facility-specific. All items are locked up and under staff control until scheduled times for use under supervision if the doctor authorizes use.

21 Most Facilities Allow Personal photos (without frames) Personal clothing 1 Alcohol-free hygiene items 2 Plastic containers Religious/faith-based jewelry item Wedding ring Items that can be collected at discharge but are locked in safe (e.g., cell phone and charger) Patients are often transferred from an ED to an inpatient facility wearing hospital-issued scrubs; changing into personal clothes is determined by the treatment team based on safety concerns and facility protocols. 2. Some facilities provide all hygiene items to try to assure nothing inappropriate will be brought to the patient.

22 Walk-In vs. Transfer From an ED Walk-In to IPF for Evaluation Patient general information/emergency contacts Insurance/payment information BH assessment/intervention 1 Patient rights and responsibilities/privacy policies Releases of information Admission or discharge with referrals ED Evaluation/Transfer 2 Admitted to the ED Patient general information/ emergency contacts Insurance/payment information Patient rights and responsibilities/privacy policies ROI Medical clearance (rule outs) BH assessment/intervention Transfer to IPF or discharge with referrals If a walk-in patient needs medical attention or higher-level medical clearance than the IPF can provide, the patient may be sent by ambulance to the nearest ED. 2. Patients are most often transported by non-emergency ambulance to the IPF; involuntary patients are transported by law enforcement.

23 Admission Orientation to the unit/area of treatment Physical layout Nurses station Emergency exits Patient room Group/activity rooms Typical schedule explained Meals Phone Groups Rules Quiet hours Smoking Phone Safety 23

24 Admission (cont.) Settle in room Join activities * Meet with various members of the treatment team * 24 *Depending on the time of day of admission and the patient s status/preference.

25 A Few Misperceptions Time Restraints Treatment Setting

26 Misperceptions About Time For these misperceptions: Length of stay is based on time needed to stabilize * and discharge decision is made by the treatment team (including the patient). One person can commit another person for years. Court-ordered evaluation and treatment Guardianship or conservatorship A patient can stay inpatient until s/he feels ready to discharge. Voluntary and AMA People are hospitalized for months or years. Safety in the least restrictive environment is the goal. 26 *Goal is to stabilize the patient inpatient as quickly as possible and then step down to the most appropriate outpatient level of care for follow-up and continued improvement.

27 Misperceptions About Restraints Psychiatric patients are put in straight jackets Restraints may be used if there is potential for someone to harm himself or others; straight jackets are no longer a common tool in IPFs. Non-physical de-escalation techniques Voluntary or non-voluntary medications Ativan Haldol Geodon 27

28 Misperceptions About Restraints (cont.) Physical Hands-on to redirect Apply soft or hard restraints (arms/legs/forehead/spit masks) Environmental Isolation Seclusion Time-out Quiet rooms Electro Convulsive Therapy (ECT) * is used to control patient behavior Controlled treatment option used inpatient and outpatient 28 *The HSAG Quarter 3 BH Educational Webinar will be about ECT: Changing the stigma and images of ECT (August 10, 2018).

29 Misperceptions About Inpatient Treatment The patient receives individual therapy Group therapy-based treatment Participation is a sign of progress and stabilization 29

30 Misperceptions About Inpatient Treatment (cont.) Medications are always recommended Medication evaluations are individualized and recommendations vary widely A patient can choose not to follow medication recommendations * 30 *Unless medications are because of an immediate safety concern or the patient is court-ordered to take medications involuntarily.

31 Misperceptions About Inpatient Treatment (cont.) Medication helps right away Some medications can be effective with the first dose, but most take weeks/months to reach a therapeutic level. Each individual person is different it can take time and trials of different medications to determine both the best medication and the right dosage. 31

32 Misperceptions About Inpatient Settings 32

33 An Emergency Department Example 33

34 Observation Area in a Medical Hospital Example 34

35 Observation Area in Behavioral Health Facility Examples 35 Image shared with permission

36 Inpatient Room in Medical Facility Example #1 36

37 Inpatient Room in Medical Facility Example #2 37

38 IPF Patient Room Example #1 38 Image shared with permission

39 IPF Patient Room Example #2 39 Image shared with permission

40 Compare 40 Image shared with permission

41 IPF Patient Common Area Example #1 41 Image shared with permission

42 IPF Patient Common Area Example #2 42 Image shared with permission

43 IPF Group/Music Room Example 43 Image shared with permission

44 IPF Cafeteria Example 44 Image shared with permission

45 IPF Smoking Patio Example 45 Image shared with permission

46 IPF Outdoor Area Example 46 Image shared with permission

47 IPF Exercise Room Example 47 Image shared with permission

48 IPF Swimming Pool Example 48 Image shared with permission

49 Treatment Team Ongoing assessment and support Psychiatrist medication Therapists lead groups, identify goals and needs Nursing/medical medication administration, monitor medical/physical/side effects 49

50 Treatment Team (cont.) Case Management coordination of care while inpatient and for discharge planning Transition Specialist post-discharge support * 50 *Ideally this is a person who meets the patient while still inpatient to establish a relationship and offer/advise of post-discharge support available.

51 Typical Expectations Daily Schedule Meals Groups Activities Personal time Individual assessments with treatment team members Phone calls Scheduled Time-limited Visits Scheduled Time-limited In a group setting* Children (minors) Special occasions/ holidays Pets Visitors belongings secured No outside food/drinks 51 *Visiting in common areas not in patient rooms, no sleepovers including with children.

52 Examples of Groups and Activities Groups Facility curriculum Coping skills Self-awareness Problem solving Community resource use Self-advocacy Discharge planning Relaxation techniques Healthy relationships Parenting Substance use related 12-Step Relapse prevention Harm reduction Activities Art* Physical activities* Movies* Journaling Crafts* Reading Music* Individualized public assistance Program education/enrollment support (SSI/SSDI/Rx Assistance) Advocacy organizations (NAMI) 52 *May be therapeutic groups or individual activities offered.

53 Daily Schedule Sample Goal: Attend 4 Groups Time Daily: consult with Psychiatrist and Case Manager Various/Concurrent Schedule Items 6:00 a.m. Quiet Time/Personal Time Smoking Patio Open 15 minutes 7:00 a.m. Breakfast/RN-medications Phone calls 8:00 a.m. Group (Therapist) Physician Exam 9:00 a.m. Chapel on Sunday Group (Therapist) 10:00 a.m. Smoking Patio Open 11:00 a.m. Group (Case Manager) Art/Music Room open 12:00 p.m. Lunch/RN-medications Exercise Options/Phone calls 1:00 p.m. Visitation or Personal Time Smoking Patio Open/Parenting Class 2:00 p.m. Group (Therapist) Social Worker Visit 3:00 p.m. 12-step organizations Group (Therapist) 4:00 p.m. 1:1 Professional Visit 5:00 p.m. Dinner/RN-medications Smoking Patio Open 6:00 p.m. Visitation or Personal Time Chapel on Wednesday/Phone calls 7:00 p.m. Exercise Options Group Activity (movie, etc.) 8:00 p.m. Art/Music Room Open 9:00 p.m. Personal Time/Quiet Time/RN-medications Phone calls/smoking Patio Open 10:00 p.m. 6:00 a.m. Lights Out/Quiet Time

54 Length of Stay Varies by Individual Variables: Detoxification process Starting medication Response to medication Response to treatment Safety considerations Discharge planning Insurance review/recommendations 54

55 Post-Discharge Discharge/wellness/transition plan Safety/crisis planning Supportive people and places Coping skill reminders 55

56 Post-Discharge (cont.) Follow-up appointments PCP Ongoing medical/physical evaluation/care Counseling Individual, couples, parenting, family Psychiatrist Ongoing psychotropic medication evaluation Other community-based support Everyday needs Food, clothing, shelter, transportation Benefit programs (SSI/SSDI, prescription assistance) 12-Step Relapse prevention Parenting Faith-based 56

57 Post-Discharge (cont.) Follow-up from IPF staff members to offer clarification and support as needed Possible referral for increased support peer programs or enhanced outpatient services/case management 57

58 When There is a Concern/Complaint IPF treatment team members Patient representative for the facility Department of Human Services 58

59 Summary There are specific criteria for inpatient admission to an IPF. There are many things to consider in selecting a treatment facility. Daily routines are usually structured and consistent. There are many restrictions in IPFs in seeking to provide a safe and therapeutic environment. 59

60 Summary (cont.) Inpatient length of stay is based on the time needed to: Stabilize a crisis or dangerous situation, and Transition the patient to continued/maintained stabilization with outpatient providers and supports. IPFs, both the setting and treatment, are different than is often portrayed in the movies. 60

61 Online Poll: What Do You Say? How do you rate your knowledge of what inpatient psychiatric treatment looks like right now? a. Very high b. High c. Low d. Very low 61

62 Questions? Please submit questions through the chat feature. 62

63 Thank you! Dennette Janus, MA, LPC, Quality Improvement Specialist, HSAG

64 Photo Contributions From: Aurora Behavioral Health System Haven Behavioral Hospital of Phoenix RI International Valley Hospital HSAG Communications Department 64

65 Prescription-Related Resources For Prescribers: Formulary Verification by Insurance Plan The easy and efficient way for physicians offices to complete prior authorization (PA) requests for any drug and nearly all health plans! Cover My Meds. A no-cost, HIPAA-compliant online resource option. or call Prescription Assistance Programs Individual pharmaceutical companies Online prescription assistance guides can help identify other programs available by drug name or medical condition and offer printable medication discount cards. or call or call Medicare Part-D A guide for applying for assistance with medication costs and for when a patient is in the Medicare Donut Hole: or call

66 Resources Available Nationwide National Suicide Hotline TALK (8255) National drug/alcohol referral service HELP (4357) #2 for Spanish Teen Lifeline: YOUTHLINE Crisis Text Line: Text help to for any crisis situation Poison Control: National Alliance on Mental Illness (NAMI) Mental Health America

67 Arizona-Specific Statewide Resources Crisis Resources Arizona Maricopa County: or Cenpatico Counties: Pinal, Pima, Gila,* Yuma, Greenlee, Graham, Santa Crus, Cochise, and La Paz: Health Choice Counties: Apache, Coconino, Mohave, Navajo, Yavapai, and Gila:* Teen Lifeline: TEEN (8336) General Community Resources: AZ 211: Call 211 or

68 Maricopa County, Arizona-Specific Resources Maricopa County Crisis Line: or Find Help Phoenix: Free and almost free services/resources Southwest Network Help Book: Community and BH resources. Mercy Maricopa Community Resource Guide: Area Agency on Aging Region 1: Resources for individuals 60+, adults with a disability and long-term care needs, or adults with diagnosis of HIV or AIDS. National Alliance on Mental Illness, Valley of the Sun: Maricopa County affiliate of NAMI. Download list for information on organizations offering 24/7 BH Level of Care Assessment. 68

69 Thank You for participating! Please go to: Complete the 60-second evaluation Download your certificate of attendance Download the resource lists at: 69

70 This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. QN-11SOW-G