JOHN GEORGE PAVILION PSYCHIATRIC EMERGENCY SERVICES (PES) CAPACITY ISSUES: Causes and Potential Solutions SYSTEM UPDATE September 26, 2016 Rebecca Gebhart, Interim HCSA Director Karyn Tribble, PsyD, LCSW, BHCS Deputy Director Guy C. Qvistgaard, Chief Administrative Officer, John George Psychiatric Hospital / Ambulatory Care, Alameda Health System
2 REVIEW Potential Solutions & Strategies PES Staffing Community Resources POTENTIAL SOLUTIONS Expand JGP Capacity ED TELE- PSYCHIATRY PILOT Existing Resources
3 Update Community Resources & Services Community Resources St Rose Tele-Psychiatry Pilot Use of Existing Resources Expansion of JGP Capacity
4 Update Community Resources & Services Community Resources Additional Mobile Evaluation Teams (MET) in Oakland & Fremont Partnerships between BHCS and Oakland and Fremont Police Departments Post Crisis Mentoring Program Goal to reduce repeat hospitalizations/ crises through positive peer support, mentoring and increased community connections and engagement. Partnership between BHCS, JGPH & NAMI South County; Innovations > Ongoing BHCS Program. Contract being finalized. St Rose Tele-Psychiatry Pilot To date, ~10% of the total 5150 holds have been discontinued, resulting in a decrease in St Rose to PES transfers. Results are promising and support further exploration of tele-psychiatry to additional emergency departments.
5 Update Community Resources & Services Use of Existing Resources Expansion of Hope Intervention Program (HIP) Goal to provide intensive case management, resource coordination and linkage to patients discharging from PES. Currently a Transition Age Youth (TAY) program with promising results. BHCS in discussions with provider (Bay Area Community Services (BACS) regarding expansion to include Adults & Older Adults. Expansion of JGP Capacity BHCS, HCSA, AHS exploring use of existing space and/or sites. Current focus on development or expansion of new services or existing community resources.
6 SUMMARY Update PES Census & Operations Census for August = 49.3 average Total registered visits from midnight to midnight + # of patients in PES at end of NOC shift who have been in PES 24 hours or greater Length Of Stay (LOS) August = 19.2 hours Number of Patients arriving daily (registered visits) 39.6 pts/day Patients staying greater than 24 hours 9.7 pts/day
7 Update JGP PES Length of Stay (LOS)
8 Update JGP PES Data Analysis PES Volumes Immediately BEFORE and After Intervention *Number of PES Patients per day (includes >24hrs) 31 days BEFORE Intervention: 5/24/2016-6/23/2016 31 days After: 6/24/2016-7/25/2016 83 days BEFORE Intervention: 4/2/2016 6/23/2016 83 days After: 6/24/2016-9/14/2016 55.7 46.5 56.0 49.5 *Total Registered visits from midnight midnight (+) # of patients in PES at the end of NOC shift who have been in PES 24 hours or greater.
PES Daily Visits - Rolling 12 months Green bars = # of registered visits Blue bars = total pts (registered visits + pts staying over 24 hours) 9 64.0 61.8 59.0 54.0 49.0 56.3 51.1 52.4 51.4 53.2 56.6 56.8 51.2 48.7 49.3 55.0 44.0 39.0 43.4 43.6 39.6 42.5 42.3 44.1 44.3 42.9 40.5 40.8 39.6 40.6 34.0 29.0 24.0 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sept MTD
10 Review PES Volumes Total Registered visits from midnight midnight, (+) # of patients in PES at the end of NOC shift who have been in PES 24 hours or greater. MONTH 53.2 March 56.6 April 56.8 May 51.2 June** 48.9 July 49.3 August 55.0 September (Month to Date) **NOTE: Change in PES provider staffing, including TRIAGE, occurred on 6/24/2016.
70 Average Daily Pt Census in PES (includes pts staying >24 hours) JGP PES - System Update (9/26/16) 11 60 50 40 30 20 10 0 Jul-12 Oct-12 Jan-13 Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15 Oct-15 Jan-16 Apr-16 Jul-16
12 Update Data Analysis and Proposed Strategy DATA: 50% of PES patients arrive as the result of a transfer from area Emergency Departments or inpatient units. PROPOSED STRATEGY: At times when conditions in PES exceeds the ability of the unit to deliver high quality services, there will be a temporary hold placed on accepting transfers from patients currently receiving care at area Emergency Departments and Inpatient Units. Transfers that have already been accepted will continue through the process and be admitted to PES. The capacity of the unit to deliver high quality services would be adjusted, based upon considerations including unit acuity, available and current staffing, space, and facilities for patient care (including ability for patients to have adequate accommodations to sit, sleep and eat).
13 PES Census Management Important Considerations The following factors will be among those taken into consideration regarding a temporary suspension of transfers from outside hospitals occurs: 1. Physical space in the unit (may cause the clinical threshold to be lower) 2. When current staffing levels are such that adding additional staff to ensure high quality care is problematic
14 PES Census Management Important Considerations (continued) 3. One-to-one staffing (may cause the clinical threshold to be lower) 4. Patients waiting for an evaluation by a physician (may cause the clinical threshold to be lower) 5. Patients with a confirmed & available disposition (may cause the clinical threshold to be higher )
15 PES Census Management Important Considerations (continued) What does census management or limiting the census mean? Once certain conditions are reached: Area EDs calling for transfers will be delayed PES activates Transfer Delay Procedure 6. Ambulances arriving from the field will continue to be accepted 7. Walk-ins will be accepted 8. Law Enforcement arrivals will be accepted
16 PES Census Management EMTALA and PES EMTALA Implications for AHS/JG Requirements under Federal regulations do not allow emergency facilities to turn away ambulances arriving from the field or walk-in patients seeking emergency care EMS Partnership Continued support of Psychiatric Evaluations 5150 Transport (Field Screening) procedures co-developed by John George Medical staff and EMS on 6/6/2012
17 PES Census Management Implications of a Census Cap in PES Area Emergency Departments would have increased wall time (unavailability of ambulances to respond to other calls) Area EDs would likely have an immediate need for increased support from psychiatrists, behavioral health personnel and county crisis teams BHCS Mobile Crisis On-call psychiatrists Social workers and other behavioral health personnel Tele-Psychiatry (St. Rose model)
18 PES Census Management Census Cap Implications (continued) Potential Impacts to Crisis System in Alameda County: Patients and families may seek alternative supports and use area Emergency Departments as refuges for crisis stabilization, albeit psychiatric expertise or consults may be limited. Increased walk-ins at PES; Potential for more field arrivals at PES; and Would require immediate coordination with EMS, Emergency Departments, and rapid build-up of county crisis services per BHCS previously stated plans. Emergency Departments would be immediately impacted potentially requiring additional staffing, patient beds (designed to support individuals suffering from mental illness), and financial resources.
19 PES Census Management Census Cap & Essential Stakeholders Area Hospitals and Emergency Departments Law Enforcement Emergency Medical Services (EMS) Labor Families (NAMI) Consumers HCSA/BHCS Board of Supervisors/Board of Trustees County Medical Societies Patients Rights Advocates
20 Next Steps Ongoing Planning & Discussion Short-Term Action Items (6-18 Months) Long-Term Planning & Action Items (12 Months +) Additional Triage Doctors at PES SB82 Grant Awards (CSU s & CRT s) Stable Psychiatrist Staffing JGP Inpatient & PES Capital Expansion St Rose Tele-psychiatry Use of Wellness Centers & Other Community Based Resources at Discharge Mobile Evaluation Teams Post Crisis Mentoring Hope Intervention Teams
21 Next Steps Exploring Additional Solutions Potential Action Items (6-18 Months) Expansion of Tele-psychiatry Projects to include other Emergency Departments Use of MHSA Innovations Funding (Community Based Responses) Exploration of system-wide discussion of Temporary Suspension of Transfers from outside hospitals.
22 QUESTIONS?