What s the BIG DEAL? Behavioral Health Integration Throughout the Continuum

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1 What s the BIG DEAL? Behavioral Health Integration Throughout the Continuum NCAHQ April 5, 2017 Monica Cooke MA, RNC, CPHQ, CPHRM, FASHRM Quality Plus Solutions LLC

2 Objectives Describe the prevalence of co-morbid behavioral health conditions Identify the risks and care concerns with behavioral patients Identify strategies improve patient safety with throughout continuums of care Discuss the advantages of behavioral healthcare integration

3 Why Are We Talking Today? Number of Americans with a behavioral health disorder? Number of Americans that will suffer a significant behavioral health issue? Leading cause of healthy life lost? Reduction in BH beds? Who has behavioral health disorders?

4 Trendwatch Healthcare reform will increase parity and broaden access to care Increase provider accountability will spur efforts to coordinate care across fragmented settings to improve the efficiency and effectiveness of care delivered to individuals with BH conditions.

5 Out of the 10 leading causes of disability in developing countries, 4 are mental disorders. By 2020, MAJOR DEPRESSIVE ILLNESS will be the leading cause of disability IN THE WORLD for women and children.

6 2015 Top 10 List of Patient Safety Concerns #3 Managing patient violence #7 Opioid Related Events

7 Liabilities/Exposures Adverse Media Attention Regulatory Risks Facility Licensure Action Health Care Professional Liability Risk

8 Frequent Legal Claims Inadequate risk assessments Lack of a safe treatment environment Lack of appropriate monitoring procedures Untrained staff Untimely transfers to appropriate setting

9 Organizational Performance Pay for Performance- Readmissions and Patient Satisfaction Length of stay: BH patient stay on medical units is twice as long

11 Prevalence Primary /Ambulatory Care Emergency Department Inpatient Units Long Term Care

12 Let s Not Forget: Employees 1/3 rd of those with BH illness are employed 1/4 th of US workforce (28 million ages18-54) have a BH or Sub abuse disorder Most common: alcohol abuse/dependence Major depression, and social anxiety 71% of workers with BH have never sought help

13 Co-Morbidity is the Norm 68% of adults with a behavioral disorder have at least one medical disorder 29% of those with a medical disorder, have a behavioral disorder

14 14

15 Mind Over Matter The mind controls behaviors Behaviors determine lifestyle Lifestyle is a major contributor to physical health status

16 Challenges in Non-Psychiatric Settings No interest in psych Minimal training/awareness Lack of system support Focus on medical conditions Unsafe treatment environments Fewer transfer options

17 Leadership Concerns ED is the primary care setting Suicides in healthcare settings Increasing healthcare aggression/violence Readmission rates (more acute episodes) Longer lengths of hospital stays Increasing healthcare costs Liabilities related to lack of treatment

18 Failure of Deinstitutionalization Political correctness NOT scientific knowledge Greedy game of cost shifting

19 Result of BH Care Disintegration Lack of treatment providers Lack of appropriate treatment settings ER s and PCP s are treating most BH patients Higher rates of pulmonary disease and other chronic conditions AND MANY SOCIETAL WOES

20 18% have anxiety disorders: 6.7% have Depression 33 MILLION obtain services (10% pop) 66 MILLION do NOT obtain services (15% of pop) 50% of BH issues begin by the age of 14: 3/4 th by the age of 24 46% of the homeless 70% of youth in prison 80% of the prisoners in the State of New York

21 WE ARE SPENDING WAY TOO MUCH IN ALL THE WRONG PLACES!

22 Top Behavioral Health Risks Substance Use Suicide Aggression Elopement

23 Opioid Epidemic 100 million (40%) of Americans have chronic pain Four fold increase in Opioid sales between 1999 and 2010 and OD deaths more than tripled The US consumes 99% of the worlds hydrocodone Hydrocodone is the most prescribed medicine in the US

24 Drug Seeker in ED

Increasing Suicides One every 14 minutes 10 th leading cause of death in US 3 rd cause of death for ages 15-24 Military/Veterans (less than 1% of the pop) represent 20%

25 Increasing Suicides One every 14 minutes 10 th leading cause of death in US 3 rd cause of death for ages Military/Veterans (less than 1% of the pop) represent 20% of suicides = 22 per day 17% involve elderly (65+) 25 attempts per completed suicide (1,000,000 per year) 31% of the clinical population and 24% of the general population 25

26 Untreated BH Disorders Increase PCP, clinic, or hospital visits. More costly tests Exacerbation medical illnesses (i.e. Pulmonary disease) Early mortality of patients Unsafe patients/staff

27 RISK MITIGATION & PATIENT SAFETY

28 Patient Assessment/Reassessment Suicide Risk Screening Initial BH Risk Assessment Changes in observation level Changes in condition Transitions in care Discharge

29 Assessment and Prevention Use screening tools for behavioral health and substance use, i.e. PHQ-9, SBIRT Prioritize attention to chronic conditions

30 Environment of Care

31 SAFE ROOMS Permanent or convertible Close to central area One room, multiple patients Use Geri-Chairs/recliners May have curtains between patients Provide diversions manage anxiety

32 Design of the Environment Garage Door Showers/Bathrooms Beds Doors/Wardrobes Windows Plastic bags Light fixtures, door knobs, sprinklers Hand rails

33 Environment of Care Initial search of patient Use of electronic wand Routine surveillance/searches Safety restrictions Security

34 Observation/Monitoring One to One (Sitter) Constant Observation Multiple Patients Q-5 to Q-15 Minute

35 A Word About Sitters Typically untrained Often not part of the team Unfamiliar with policies Blamed when things wrong No evidence to support they decrease risk go

36 Safety Contracts? No longer standard practice False sense of security No evidence that they prevent suicide, determine lethality or mitigate liability Not legally binding

37 Competencies Medical/nursing staff/supervisors Maintenance

38 Minimal Competencies Assessment/Reassessment Respectful approaches Predicting/identifying escalation De-escalation techniques Non-violent crisis intervention Restraint/seclusion Workplace violence program Documentation

39 Restraint & Seclusion Consensus that restraint and seclusion are safety interventions of last resort Restraint /seclusion is a BH CODE BLUE Physical restraint often done: lack of compliance Chemical restraint: often done in ED Documentation is essential Restraint Reduction Committee

40 BH Resources Behavioral Health Technicians Licensed Psychiatric Social Workers Advance Practice Nurses Psychiatry Tele-Psychiatry Behavioral Health Rapid Response Team

41 Communication/Documentation Huddles Hand offs/shift Report Assessments/Observations/ Interventions Discharge assessment

42 Discharge planning Weapons, drugs, stock medication at home Clear discharge instructions Establish follow up appointment

43 Primary Care Develop competencies Improve recognition and symptom management Annual screening Provide referral information for all patients

44 Quality & Risk Management Culture of Reporting Collect, Analyze, Trend Root Cause Analysis Debriefing/Learning from Defects Conduct a risk assessment of the care of the BH patient throughout the continuum

45 Behavioral Health Care Integration Medical and BH providers team together for good health outcomes High quality coordinated healthcare The principles of good care are not systematically (routine) applied on a broad scale for good care Patient-Centered Medical Homes synthesize these care functions

46 Types of Care Integration A fully integrated care model Partnership model shared across two organizations Facilitated referral approach in which there is coordinated care at multiple locations

47 Advantages Improved Access Attention to treatment preferences Coordination & continuity of care Improved overall care and outcomes

48 Outcome Success: Readmission Rates 2012 Study with Unity Point-Trinity 79% of readmissions had BH disorder When addressed, readmission rate fell to 8% in 2 MONTHS. IMPACT project Return on investment: $6.00 saved for each $1.00 spent on the program Study: ED visits were 42% lower with integrative primary care services

strategies can assist in reducing potential liabilities, improve care, and

49 CONCLUSION The numbers of BH patients is not likely to decrease any time soon Organizations need to focus on care integration Care coordination and safety strategies can assist in reducing potential liabilities, improve care, and reduce costs Health systems have a responsibility to provide care to the whole person

RESOURCES o Sine, David, Hunt, James. White paper: Design Guide for the Built Environment, 5.1 Edition, 2012, www.fgi.

50 RESOURCES o Sine, David, Hunt, James. White paper: Design Guide for the Built Environment, 5.1 Edition, 2012, o OSHA Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers DisturbingNews/Guidelines%20for%20PreventingViolence%20HSS.htm o The Joint Commission, Sentinel Event Alert #46, o Rozovsky, Fay and Conley, Jane, Health Care Organizations Risk Management: Forms, Guidelines, and Checklists. Third Edition, Chapter 12 Behavioral Health Risk Management, Aspen Publishers, 2009

51 Resources AHA, Your Hospital s Path to the Second Curve: Integration and Transformation, January 2014 ECRI Institute, www. Ecri.org AHA, integrating Behavioral Health Across the Continuum of Care, February, AHA Trendwatch, Bringing Behavioral Health into the Care Continuum: Opportunities to Improve Quality, Cost, and Outcomes, January 2012 Robert Wood Johnson Foundation, The Synthesis Project, Mental Disorders and Medical Comorbidity, February 2011 AHRQ Healthcare Cost and Utilization Project, Statistical Brief #160, National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2011, August 2013 World Health Organization, Department of Mental Health and Substance Abuse, Promoting Mental Health: Concepts, Emerging Evidence, Practice, 2005

Patient Health Questionnaire -9 Audit Screener for Alcohol Sitter Guidelines SbIRT- Screening and Brief Intervention http://www.cdc.

52 Patient Health Questionnaire -9 Audit Screener for Alcohol Sitter Guidelines SbIRT- Screening and Brief Intervention Screening tools for Psych and SA conditions 52

53 THE END Thank you for participating in this session. Proceed With Confidence! Questions/Comments Monica Cooke

Behavioral Health Risk in the Acute Care Setting

Behavioral Health Risk in the Acute Care Setting Arizona Society for Health Care Risk Management May 20, 2011 MONICA COOKE MA, RNC, CPHQ, CPHRM QUALITY PLUS SOLUTIONS LLC OBJECTIVES Identify the degree