Team Building Storyboard Template Storyboard purpose: To assist teams in telling their team members and organization s story. Behavioral Health Discharge Management Team Motto: We provide quality patient care. Team Members: Names and Strengths 1. Jazmin Hunter, Determination 2. GB Watson, supportive 3. Jessica Sikorski, organized 4. Stephanie Geis, determination 5. Deidra Saina, open to learning
The work of your organization Services: Comprehensive Behavioral Health Discharge Management Program Geographic region served: Tarrant County Population of focus for Care Transitions improvement: All patients discharging from Trinity Springs Pavilion DSRIP Project Topic/s that relate to Care Transitions: Improve care transitions and coordination of care from inpatient to outpatient How improving Care Transitions supports your organization s mission and goals: This project will provide greater management that will result in improved post-discharge engagement and treatment adherence, the rate of readmission for the psychiatric services and the general availability inpatient and intensive services for the significant volume of Medicaid and uninsured psychiatric patient discharging from TSP.
Improving Behavioral Health Outcomes through Discharge Management JPS Health Network, Trinity Springs Pavilion Fort Worth, Texas What is Behavioral Health Discharge Management? A comprehensive transition management program focused on assisting patients in the transition form inpatient psychiatric services to the community Transition Coordinators will engage in proactive pre- and post-discharge interaction, intervention, and coordination as patients discharge from an inpatient facility and return to the community. Staffing: 3 Fulltime Social Workers, Peer Support Specialists, Peer Support Supervisor Aims Increase number of the patients/families provided with appropriate discharge education by 75%. Increase number of High Risk Patients who are discharged with customized care plans by 60%. Increase patients who receive 3 attempted clinician follow-up calls to review treatment plans and assess compliance after discharge by 75%. Increased number of patients receiving follow-up after hospitalization for mental illness within 7 and 30 days by 5% and 7.5% over life of project. Reduce behavioral health/substance abuse 30- day readmission. Decrease mental health admissions/readmissions to criminal justice settings such as jails or prisons. Reduce inappropriate emergency department visits for behavioral health. Evaluating the Issue Baseline readmission rate: 7.15% Patients with multiple readmissions within 30 days of index admission were only counted once Readmission rate is for adults only Excluded any patient transferred to another hospital (including state hospital) PLAN Project planning with stakeholder groups (Physicians, staff, management, IT, Knowledge Management, etc.) Hold monthly Discharge Management and Patient and Family Advisory Council meetings Hire Transition Coordinators, Peer Support Specialists Develop and complete several PDSAs Identify predictors for readmission through compilation/review of data NOTE: All cycles included feedback or participation from patient and family advisory council members DO Aim: Improve patient follow-up appointment attendance by scheduling it prior to discharge at Trinity Springs Use the Standardized Discharge Planning Checklist within 24 hours of discharge; schedule follow up appointment with a mental health provider prior to discharge and call each patient 24 hours prior to follow up appointment to remind them of their appointment. Aim: Connect MHMR-active patents who present in the PEC for medication refills back to their MHMR clinic. Verify patients are MHMR-active, complete EMS to determine patient stability, have patient meet with MHMR staff member regarding patient needs. Aim: Improve communication regarding long acting injections to ensure patients have access and resources needed to receive injections after discharge Increase collaboration/education surrounding long acting injections; review charts of patients discharged on long acting injections. Use sticky notes in EPIC; add follow up injection reminder to social worker task list/dc summary; add injection section to Daily Treatment team notes. Multidisciplinary Treatment Team Multiple Cycle PDSA Aim: Improve communication, provide a consistent message to the patient regarding their discharge plan and communicate to the next care provider. Treatment teams (Nurses, Social Workers) meet daily; document in treatment team note: Who was there, patient discharge disposition, other pertinent information. Aim: Increase rate of patient enrollment in JPS Connection prior to discharge Social Workers/business office staff work with patient to complete application in a timely manner. STUDY Results: Patient follow-up appointment attendance rate improved from 20% to 60% Next steps: Expand sample size, provide a patient discharge planning checklist, add phone call scripting for follow-up calls Results: Fewer active MHMR clients arrive to the PEC for medication refills than previously thought. Next steps: Expand data collection and look for other trends in PEC utilization. Results: Increased number of patients attended their follow-up injection appointment; improved documentation of long acting injections in the discharge note and improved communication with follow-up provider regarding long-term injections. Next steps: Continue to test the effectiveness of using the treatment team smart note. Multidisciplinary Treatment Team Multiple Cycle PDSA Results: Increase in number of charts that contain multidisciplinary treatment team notes. Next Steps: Social workers need coaching on what information needs to be documented; revise some wording in notes; multi-disciplinary team meetings to occur with all treatment teams (evaluate need for nurse assignment) Results: Increase in number of patients who are JPS Connected prior to discharge Next steps: Continue to work one-on-one with patients and families to complete the paperwork for JPS Connection. Predictors PHASE 1 PHASE 3 for PHASE Readmission 2 PHASE 4 PHASE 5 10 Interviews Key Points: Readmission Time 0-5 Days: 4 pts 6-15 Days: 3 pts 16-30 Days: 1 pt 31+ Days: 2 pts 250 Chart Reviews Reviewed days from DC to readmit Age & Gender Dx Categories Financial Status General Themes Zip Codes 30 Day Readmission Rate Baseline Rate of 7.15% Observed over Expected 18-40 yo Males more likely Dx: Schizophrenia, bipolar, substance abuse, medical, psychosis LOS: 4-10 days Race: AA, PI, Asian, AI Ethnicity: Not Hispanic or Latino Predictors of Readmission Dx: Bipolar, Psychosis, Schizophrenia, substance abuse Age: 55-60 yo Race: Black & Asian Ethnicity: Not Hispanic Zips: 76116, 76010 ACT The team advanced from simple trend analysis to observed over expected ratios to a tool that used statistical significance and degree of correlation to predict which patients were most likely to readmit. Diagnosis CRITERIA Patient meets Criteria Score Bipolar Disorder YES 2 Psychosis NO 0 Schizophrenia NO 0 Substance Abuse YES 2 Age 56-60 NO 0 Race BLACK OR AFRICAN AMERICAN YES 1 ASIAN NO 0 Ethnicity NOT HISPANIC OR LATINO YES 2 Zip Code 76116 YES 1 76010 NO 0 Total Risk Score: Risk for Readmission: SCORE 6 HIGH RISK for readmission SCORE 3-5 MODERATE RISK for readmission 3 Intervention categories based on risk: SCORE 2 LOW RISK for readmission High risk for readmission- 6 month follow-up post discharge Moderate risk for readmission- 3 month follow-up post discharge Low risk for readmission- 30 day follow-up post discharge Interventions from the Chronic Care Model (Wagner) Components from RED (Re-Engineered D/C) Focus on improved discharge coordination Focus on care plans, d/c calls, medication adherence Get detail in scripts for follow-up calls Components from the Care Transitions Program (4 pillars) Medication Self-Management Patient centered record Follow-up with provider Knowledge of red flags or warning signs/ symptoms and how to respond 8 High
Care Transitions Targets, Current State Work Completed and still in progress Patient & Family Advisory Council Monthly Meetings Staff Hired for the implementation process: Transition Coordinators, Peer Support Specialists Completed several PDSAs Multidisciplinary Treatment Team Multiple Cycle PDSA More PDSA s to come Developed a Risk for Readmisison Tool Epic changes to capture accurate data
Care Transitions Partners JPS Health Network MHMR