2015 IHS PUBLIC HEALTH NURSING, COMMUNITY BASED PHN CASE MANAGEMENT SERVICE

Transcription

1 2015 IHS PUBLIC HEALTH NURSING, COMMUNITY BASED PHN CASE MANAGEMENT SERVICE PHN PROGRAM AWARDS (COMMUNITY SUICIDE PREVENTION PINE RIDGE SERVICE UNIT AND THE GREAT PLAINS AREA) PHN Rodney R. Sahr RN, BSN 1

2 IHS HQ PHN Funded Initiative 2015 PHN Program Award $150,000 per year for 3 years to support a PHN Case Management Program in Pine Ridge re: suicide prevention in the community (Funded July 2015) PHN Case Management Program as a Best Practice and model for replication The PHN Case Management Program is mission critical, supports and promotes high quality patient care and targets suicide prevention in the community. Duties and activities of the PHN Case Management Program: Develop PHN case management services for suicide prevention in the community; Coordinate patient care services among health care site (hospital) and the community (home) to improve quality of care; Use the PHN model of community based case management to target suicide prevention; and, Increase transparency in all aspects of patient care activities through open communication with Tribal and Federal programs. 2

3 Background The IHS Public Health Nursing (PHN) is a community health nursing program that focuses on the goals of promoting health and quality of life and preventing disease and disability. The PHN program provides quality, culturally sensitive health promotion and disease prevention nursing services through primary, secondary and tertiary prevention services to individuals, families, and community groups. 3

4 Purpose The purpose of the IHS PHN Program Award Program is to improve specific health outcomes of an identified high risk group of patients through a community case management model that utilizes the PHN as case manager. Research indicates nursing case management is a cost effective way to maximize health outcomes. Case management involves the client, family, and other members of the health care team. 4

5 Key Emphasis - Targeted Agency Initiative: The Pine Ridge PHN Program will report on performance measures for suicide prevention in the community that will be monitored for program improvement and sustainability efforts. The goals and outcomes of the PHN case management service are early intervention and evaluation that will improve health outcomes in a cost effective manner. (1-2) 5

6 This utilizes all prevention components of primary, secondary and tertiary prevention in the home and community with the patient and family. The community based case management model includes the PHN scope of practice of working with individuals and families in a population-based practice to provide primary nursing care services and follow up. The project will be conducted in a phased approach, using the nursing process - assessment, planning, implementation, and evaluation

7 First Phase: Assessment Complete a community assessment to include other pertinent data from reports on the suicide activity in the community and other related issues. 7

8 Second Phase: Planning Based on the findings of the community assessment and other suicide data reports, begin to plan the case management project. Develop case management services addressing the priority health issues identified. Plan specific guidelines for the case management services of the high risk group of patients such as admission criteria, caseload size, policies and procedures, and an evaluation plan to include 8

9 data tracking for outcomes generated. Identify if there is a best practice case management model available to replicate to target the identified high risk population. In regards to suicide prevention, obtain additional staff training needed such as evidence based practice, motivational interviewing, staff competencies and any other training that would be applicable to suicide prevention. Plan what PHN intervention will be provided during the home visit and how this activity will be monitored. Identify or develop patient education materials and community education materials for the program. Develop plans for project sustainability. 9

10 Third Phase: Implementation The case management program includes admission criteria, caseload size, and appropriate care standards. Establish patient caseload and guidance for home visits and the intervention to be implemented. Monitor progress and make adjustments as needed. Track patient data outcomes (number of suicide prevention activities in the community, patients contacted, number of home visits, etc.). Continue to plan ongoing sustainability of the program after the award period ends. 10

11 Fourth Phase: Patient Satisfaction In order to evaluate program services; initiate a patient satisfaction program, such as one that provides patients with an opportunity to provide feedback on their experiences to assess the satisfaction of the population served. Analyze findings so a concentrated effort is made to relate the customer satisfaction results to internal process metrics, and examine trends over time in order to take action on a timely basis. Evaluate and revise the case management program if needed, review policies and procedures, education materials and staff competencies semi-annually. 11

12 Pine Ridge Service Unit is a 45 bed Hospital serving a Sioux Indian population of more than 17,000. The geographical coverage area is approximately 2.1 million acres across three counties. It s the largest service unit in the Great Plains Area, and has two Ambulatory Health Care Centers remotely located. The U.S. Census Bureau indicates Oglala Lakota County (renamed in May of 2015 from Shannon Co.) has a population estimate of 14,218 that is 92.9% American Indian/Alaska Native. The per-capita money income in past 12 months (2013 dollars) is $8,768 making it the poorest county in the United States. It s further estimated that 53.2% of persons in the county live below poverty level. 12

13 South Dakota is ranked 9 th in the Nation for Suicide Death Rates (2015) and suicide is the 9 th leading cause of death overall. It s the 1 st leading cause of death for ages 15-24yrs, 2 nd leading cause of death for ages 25-34yrs, 3 rd leading cause of death for ages 35-44yrs, 5 th leading cause of death for ages 45-54yrs, 7 th leading cause of death for ages years and 20 th leading cause of death for ages 65 & older ( 13

14 An internal review of Pine Ridge Service Unit RMPS/EHR data shows the following age and gender distributions for documented suicidal ideation : AGE & GENDER DISTRIBUTION FOR PATIENTS WITH SUICIDAL IDEATION 2014 TOTAL MALE 0 FEMALE TOTAL MALE 1 FEMALE TOTAL MALE FEMALE YRS YRS 30-45YRS YRS YRS YRS 14

15 There are a number of other things that put people at risk of suicide including the following: -Substance abuse -Access to firearms -Gender (male) -Isolation -Intoxication -Chronic mental illness -History of trauma -Recent tragedy or loss -Agitation and sleep deprivation 15

16 An internal review of Pine Ridge Service Unit RMPS/EHR data shows the following mental health conditions for all ages 2014: 2014 TOTAL 272, 5% 2239, 38% 23, 73, 186, 0% 1% 90, 3% 2% 1309, 22% 1722, 29% ANXIETY DEPRESSION BIPOLAR PTSD SCHIZOPHRENIA SCHIZOAFFECTIVE DISORDER SUBSTANCE ABUSE SUICIDE IDEATION 16

17 Depression and Substance Abuse are the two leading mental health conditions and the following provides and age and gender distribution of these high risk comorbidities: Age & Gender Distribution For Patients With Depressive Disorders 2014 TOTAL MALE FEMALE TOTAL MALE FEMALE TOTAL MALE FEMALE YRS YRS 30-45YRS YRS YRS YRS 17

18 Project criteria and goals include ensuring staff receive current training in motivational interviewing, Mental Health First Aid and Trauma Informed Care. Collaboration with Behavioral Health (BH) & Primary Care Providers (PCP) identifying clients needing case-management and home care follow-up Collaboration with BH & PCP for care planning on clients admitted to PHN Case Management services Coordination with external partners such as Community Health Representatives, Veteran s Administration, Tribal outreach programs and Tribal transportation arranging for care needs Developing care transitions policies & procedures in compliance with Federal and State statutes integrated with hospital discharge planning committee Establishing processes for care delivery and coordination between PHN Case Management Behavioral Health Primary Care Provider (e.g. team meetings) Develop and provide a comprehensive community education and training related to mental health interventions ( 18

19 Program Plans : Program plans will include the individual/family/community approach to population management. The PHN Case Manager will admit patients to case management on a weekly/bi-monthly/monthly basis depending on the assessed need. This may also include visits with family and care-givers as needed to improve the social care aspects. Clients will be assessed utilizing motivational interviewing techniques, educated and managed to improve adherence to Behavioral Health and Primary Care Provider care planning. Including but not limited to medications and follow-up visits. Another component of the plan will include the community training. PHN s will complete instructor training in Mental Health First Aid to provide community members such as Community Health Representatives, Healthy Start staff and School staff training to recognize mental health crisis and learn intervention strategies. This will be ongoing throughout the year and service all communities across the reservation. 19

20 Section 2: Program Evaluation The PHN Case Management program will improve the coordination of care for high risk mental health diagnosed individuals and families with the expected benefits of medication compliance, adherence with follow-up behavioral health and primary care provider s visits as well as improved coordination between behavioral health and primary care management. There will also be an improvement in community educational activities for mental health recognition, intervention techniques and crisis intervention using evidence based programs such as mental health first aid. PHNs will be trained as instructors to provide these activities across the reservation. There will also be improved documentation of mental health and substance abuse screening to patients with ambulatory (face-to-face) PHN visits, and those with positive screens will be referred to Behavioral Health as well as admitted to the PHN Mental Health Case Management program improving engagement and follow up activities. 20

21 Measures PHN Program report are already used to track referrals and activity. DPHN will keep a report identifying how many referrals are received specifically for mental health and substance abuse issues. PHN Case Manager will track how many of these referrals have been completed and report how many cases have been admitted to PHN follow up services (weekly/bi-monthly/monthly surveillance) as well as the status (admitted/discharged to PHN services). DPHN will also track the community education component and report how many presentations/education classes are done on a monthly basis. This information will be sent to the Great Plain Area PHN Consultant in the monthly program report. 21

22 Use of RPMS and i Care to Report and Track Benchmarks Denominator is the number of referrals to PHN related to mental health/substance abuse/suicide ideation/suicide attempt with numerator of completed PHN follow up home visit(s). Include number of referrals remaining in pending status. Benchmark goal will be 90% with completed PHN follow-up. Denominator is number of patients currently admitted to PHN Mental Health Case Management compliant with follow up visits. Numerator is patients that kept appointments and/or follow up visits with PHN and Behavioral Health as identified by plan of care. Benchmark will be 90% with plan of care compliance 22

23 Quarterly measureable objectives include: Denominator is number of patients in case management program with ambulatory PHN visits and numerator is patients with documentation related to education and plan of care compliance (may include medication adherence and follow up adherence with Primary Care/Behavioral Health). Benchmark will be 95%. Denominator is number of all clinic code 11 visits by PHN program with numerator of documentation related to age appropriate depression screen, alcohol screen, tobacco screen and intimate partner violence screening. Benchmark will be 95%. Denominator is number of all clinic code 11 visits by PHN program that have a positive screen (defined above) with numerator of how many received referral to appropriate entity. Tobacco referred to PHN or Pharmacy cessation clinic. All others referred to Behavioral Health. Benchmark will be 95%. 23

24 COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS) Lifetime Recent - Clinical 24

25 COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS) Lifetime Recent 25

26 COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS) Since Last Visit - Clinical 26

27 COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS) Lifetime Recent 27

28 PHQ9 Depression Screening 28

29 Behavioral Health First Aid Adult & Youth 29

30 PHQ2 Depression Screening 30

31 Excel Spread Sheet for Suicide Ideations, Attempts, and Completed 31

32 Daily Count of Suicide Behaviors Pine Ridge

33 Daily Count of Suicide Behaviors- Pine Ridge

34 i Care Community Alerts Data 34

35 Highlight the rows that you want to exported to your excel spreadsheet 35

36 Aggregate Suicide Form 36

37 Emergency Room System Indian Health Service Version

38 Case Management and Surveillance Notification Tickler system 38

39 Manage Monthly lists of Referral Patients 39

40 Developing Policies Consultation to Public Health Nurse Case Manager 40

41 Zero Suicide: This public health issue affects everyone: families, healthcare providers, school personnel, faith communities, friends, government, and others. It s important that everyone know suicide s warning signs and how to help a person contemplating suicide. This is particularly true for healthcare providers, especially those who work in integrated health settings, which are primed to make a great difference in the lives of people at-risk of suicide. 41

42 Suicide is a complex human behavior, with no single determining cause. The following groups have demonstrated a higher risk for suicide or suicide attempts than the general population: American Indians and Alaska Natives People bereaved by suicide People in justice and child welfare settings People who intentionally hurt themselves (non-suicidal self-injury) People who have previously attempted suicide People with medical conditions People with mental and/or substance use disorders People who are lesbian, gay, bisexual, or transgender Members of the military and veterans Men in midlife and older men 42

43 What is Integrated Care? Integrated care is the systematic coordination of general and behavioral healthcare. Integrating mental health, substance abuse, and primary care services produces the best outcomes and proves the most effective approach to caring for people with multiple healthcare needs. 43

44 SBIRT: Screening, Brief Intervention, and Referral to Treatment 44

45 Motivational Interviewing Strategies and Techniques: ASKING PERMISSION Rationale: Communicates respect for clients. Also, clients are more likely to discuss changing when asked, than when being lectured or being told to change. Examples of Asking Permission Do you mind if we talk about [insert behavior]? Can we talk a bit about your [insert behavior]? I noticed on your medical history that you have hypertension, do mind if we talk about how different lifestyles affect hypertension? (Specific lifestyle concerns such as diet, exercise, and alcohol use can be substituted for the word lifestyles in this sentence.) 45

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