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
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
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?
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.
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.
2015 Top 10 List of Patient Safety Concerns #3 Managing patient violence #7 Opioid Related Events
Liabilities/Exposures Adverse Media Attention Regulatory Risks Facility Licensure Action Health Care Professional Liability Risk
Frequent Legal Claims Inadequate risk assessments Lack of a safe treatment environment Lack of appropriate monitoring procedures Untrained staff Untimely transfers to appropriate setting
Organizational Performance Pay for Performance- Readmissions and Patient Satisfaction Length of stay: BH patient stay on medical units is twice as long
Prevalence Primary /Ambulatory Care Emergency Department Inpatient Units Long Term Care
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
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
Mind Over Matter The mind controls behaviors Behaviors determine lifestyle Lifestyle is a major contributor to physical health status
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
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
Failure of Deinstitutionalization Political correctness NOT scientific knowledge Greedy game of cost shifting
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
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
WE ARE SPENDING WAY TOO MUCH IN ALL THE WRONG PLACES!
Top Behavioral Health Risks Substance Use Suicide Aggression Elopement
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
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% 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
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
RISK MITIGATION & PATIENT SAFETY
Patient Assessment/Reassessment Suicide Risk Screening Initial BH Risk Assessment Changes in observation level Changes in condition Transitions in care Discharge
Assessment and Prevention Use screening tools for behavioral health and substance use, i.e. PHQ-9, SBIRT Prioritize attention to chronic conditions
Environment of Care
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
Design of the Environment Garage Door Showers/Bathrooms Beds Doors/Wardrobes Windows Plastic bags Light fixtures, door knobs, sprinklers Hand rails
Environment of Care Initial search of patient Use of electronic wand Routine surveillance/searches Safety restrictions Security
Observation/Monitoring One to One (Sitter) Constant Observation Multiple Patients Q-5 to Q-15 Minute
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
Safety Contracts? No longer standard practice False sense of security No evidence that they prevent suicide, determine lethality or mitigate liability Not legally binding
Competencies Medical/nursing staff/supervisors Maintenance
Minimal Competencies Assessment/Reassessment Respectful approaches Predicting/identifying escalation De-escalation techniques Non-violent crisis intervention Restraint/seclusion Workplace violence program Documentation
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
BH Resources Behavioral Health Technicians Licensed Psychiatric Social Workers Advance Practice Nurses Psychiatry Tele-Psychiatry Behavioral Health Rapid Response Team
Communication/Documentation Huddles Hand offs/shift Report Assessments/Observations/ Interventions Discharge assessment
Discharge planning Weapons, drugs, stock medication at home Clear discharge instructions Establish follow up appointment
Primary Care Develop competencies Improve recognition and symptom management Annual screening Provide referral information for all patients
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
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
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
Advantages Improved Access Attention to treatment preferences Coordination & continuity of care Improved overall care and outcomes
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
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.org o OSHA Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers http://www.dangerousbehaviour.com/ DisturbingNews/Guidelines%20for%20PreventingViolence%20HSS.htm o The Joint Commission, Sentinel Event Alert #46, http:// www.jointcommission.org 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
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, 2014. 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.gov/injuryresponse/alcoholscreening/pdf/sbi-implementation-guide-a.pdf Screening tools for Psych and SA conditions http://www.integration.samhsa.gov/clinicalpractice/screening-tools#drugs 52
THE END Thank you for participating in this session. Proceed With Confidence! Questions/Comments Monica Cooke MCooke@QualityPlusSolutions.com 301-442-9216 53