Toronto s Mental Health and Addictions Emergency Department Alliance Ian Dawe, MHSc, MD, FRCP(C) Physician-in-Chief Ontario Shores Centre for Mental Health Sciences Head, Division of General Psychiatry Associate Professor, Department of Psychiatry University of Toronto 6/22/2011
Learning objectives To enhance knowledge of: The City of Toronto s Mental Health and Addictions Emergency Department Alliance (Alliance) Answers to important questions such as : What resources exist within Toronto (Ontario, Canada) Emergency Departments to serve people with mental health and addiction needs? How much are these resources being used? Who is using Toronto Emergency Departments for mental health and addiction needs? How are people moving into, through and out of Toronto Emergency Departments? How were the Health Leaders and MDs engaged? 2
The Mental Health and Addictions Emergency Department Alliance Alliance Steering Committee Medical Director Manager and Flow Coordinator Alliance Partner Hospital IP Medical Directors Alliance Partner Hospital PES Medical Directors Alliance Frequent Users Work Group Seniors Mental Health Working Group Common Assessment Working Group Inter-Hospital Bed Access Model Working Group Indicators of Alliance Impact Working Group
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Toronto s MH&A Emergency Department opportunity 2004-7 Issues Consumer and family dissatisfaction Variable priority given within each organization Inter-organizational silos; limited coordination Resource limitations Stigma and discrimination System Transformation Opportunity Collaborate to improve how MH&A services are delivered in downtown Toronto Emergency Departments Supporting enablers Opportunity for improvement long identified Toronto Central LHIN focus on mental health and addictions Government priority to reduce Emergency Dep t wait times Interest across organizations to work together 5
The Flow Map current state Success/leading/ evidence-based practice Issue/ challenge How people enter EDs Once in a TC LHIN ED** coordination across How people leave EDs SJHC CAMH MSH UHN SMH SHSC MH&A EDA Ad hoc vs. systemic collaboration/ organizations TEGH Hard to transfer people across organizations Disposition often determined by resource availability, not the person s needs MCITs Walks-in alone Comes with/brought by family, friend or neighbour Sent by primary care provider or community psychiatrist Sent by community worker/organization* Accompanied by community worker/ organization* Transferred by acute care/psychiatric hospital Brought by crisis team (community; MCITs) Brought in by police Brought in by EMS Sent/transferred by criminal justice system (corrections facilities/courts) Limited capacity of/ insufficient communication about the existing available alternatives to the ED Voluntary Bribed/coerced Involuntary First-time visit Repeat visit Multiple visits to multiple sites Chose site Did not choose site Ill physical health Physically healthy Safety concerns (for self and/or others) No safety concerns Connected to supports Unconnected TC LHIN resident City of Toronto GTA and beyond People brought to ED with shortest wait vs. one with most appropriate services Variety of fast forward processes Insufficient ability to respond competently to the needs of Toronto s diverse populations (e.g., ethnocultural groups, transitionalaged youth, etc.) Triage (nurse) Registration (worker/nurse) ED team; can include: Nurse Social worker Students Resident(s) (if on) MD Other staff (e.g., security) Large number of people involved in care Psychiatric Emergency Services team (n/a for MSH; if needed, refer to CAMH); can include: Nurse Social worker Psychiatric assistant Resident(s) (if on) MD Other staff (e.g., security) Little/no consistent information collected and reviewed across the system Variation in practice at the individual level Short-stay/ assessment beds Little infrastructure for research Insufficient ability to identify subacute addiction needs Addictions specialist in the ED Environment not typically conducive for people with mental health and addiction needs Lengthy waits often experienced through all parts of the process Psychogeriatric specialist in the ED Admitted Varying models of service delivery Insufficient capacity and flow through some communitybased services Transition between hospital and community services not always well managed No bed; wait in ED until bed available or admission no longer needed Few complex care community services Leave under own volition Without being seen by a physician Against medical advice Discharged Without referral or follow-up appointment Discharged With follow-up appointment within same organization With referral to hospital service provider With referral to community service provider Partnerships with selected community services Inpatient beds not available when needed Admitted No partnerships with community providers at the system level Day/outpatient services for follow-up Management of inpatient flows Transferred to bed in same organization Psychiatric Medical Transferred to bed at different organization * For example: social service agency; community mental health agency; addiction treatment organization; long-term care home; school/college/university; community service organization; other organizations ** Excludes The Hospital for Sick Children Source: Team analysis 6
Partners, purpose and projects Partners Purpose Projects SHSC SJHC MSH CAMH Provide the right care, in the right place, at the right time in a respectful, client-centred manner through a collaborative process of reforming existing emergency mental health & addictions services MH&A ED Alliance Project Team Standardized assessment form Inter-hospital bed access model Psychogeriatric popl n demo n SMH TEGH UHN Reduce Emerg y Dep t wait times Ensure delivery of consistently high quality care Improve consumer and family satisfaction Increase capacity to serve specific populations Indicators of Alliance impact Frequent user popl n demo n Community partnership devel t Consultation with consumers, family members and community-based service providers * CAMH = Centre for Addiction and Mental Health; MSH = Mount Sinai Hospital; SHSC = Sunnybrook Health Sciences Centre; SJHC = St. Joseph s Health Centre; SMH = St. Michael s Hospital; TEGH = Toronto East General Hospital; UHN = University Health Network 8
4. Our projects and anticipated outcomes Projects, purposes and anticipated outcomes Project Purpose Anticipated outcomes Standardized assessment form project Inter-hospital bed access model Improve the consistency of approach to assessment and data collection across Toronto Central LHIN EDs Increase people s access to the services they need when they need them More consistent interdisciplinary approach to assessment and its documentation across the MH&A EDA sites More consistent approach to data collection across Toronto Central LHIN Emergency Departments Increased amount of, easier and more effective inter-organization communication and decisionmaking in patient transfer situations Increased consumer and family satisfaction with their ED experience Implementation of a protocol to facilitate and track MH&A patient transfers among MH&A EDA hospitals Reduced number of people waiting in admit-no-bed status for reduced lengths of time Improved quality of care Increased consumer and family satisfaction with their experience 9
Projects, purposes and anticipated outcomes (cont d) Project Purpose Anticipated outcomes Seniors MH&A project Frequent user project Improve the quality, consistency, and seamlessness of MH&A ED services to seniors Improve the quality of care provided to frequent users of Toronto Central LHIN Emergency Departments Set of best practice clinical guidelines and hospitalcommunity communication and linkage protocols Improved consistency and quality of care across MH&A EDA sites Reduced wait times in EDs More seamless transitions for seniors moving between community (e.g., CCAC services, Long-Term Care Homes, Outreach Teams) and ED services Increased consumer and family satisfaction with their ED experience Set of best practice clinical guidelines and hospitalcommunity communication and linkage protocols Improved consistency and quality of care across MH&A EDA sites Reduced use of and wait times in EDs for frequent users of MH&A ED services Increased connection and more seamless transitions for frequent users of MH&A EDA services with hospital outpatient and community-based services Increased consumer and family satisfaction with their ED experience 10
Projects, purposes and anticipated outcomes (cont d) Project Purpose Anticipated outcomes Indicators of Alliance impact Accurately track and report on the volumes and flow of people with MH&A needs through Toronto Central LHIN EDs Set of standardized utilization and outcome indicators and related data collection, reporting and continuous improvement processes/ infrastructure Increased ability to identify, capitalize and evaluate the impact of continuous improvement initiatives both at the individual hospital and system level 11
The Process of Change
Engaging MDs as EHLs in a Change Process Key Strategies Recognize strong orientation towards achievement Recognize pride in achievement and opportunities to disseminate results Hold responsible and accountable Provide recognition early and often 13
Ladder of Engagement Level Positioning Examples 8 Engagement 7 Management 6 Collaborative 5 Consultative 4 Supportive 3 Tokenism 2 Decoration 1 Manipulation MDs have ideas, set up project, and invite others to join in decision making. MDs have initial idea and decide how project is carried out; MDs take charge. Others have idea and MDs are involved in each step of project planning and implementation. Project designed/managed by others but MDs are consulted. Their views and input are valued. Others decide on project. MDs volunteer their support and others respect their views. MDs are asked for their opinions and have little to no control over how views are expressed. MDs take part in a project/initiative. MDs do or say what others instruct them to. Adapted from: Hunt, JC et al. Engaging the next generation of health leaders: Perspectives of emerging health leaders Healthcare Management Forum Spring 2011 14
Data Collection
Summary snapshot monthly indicators Indicator July 10 August 10 September 10 July-Sept. 10 Avg. number of MHA visits per day to Alliance hospitals 99 95 93 95 Total 3,057 2,935 2,777 8,769 Total number of MHA visits Period low per day 80 70 75 70 Period high per day 120 119 121 121 Avg. number of MHA visits per day by hospital Low 4.9 5.5 4.4 5.0 High 19.3 18.9 18.6 18.9 Proportion of time EDA system in surge 19% 36% 10% 20% Proportion of time EDA system in contraction 16% 32% 13% 23% Proportion of time EDA system not surging/contracting simultaneously 65% 32% 77% 57% % of MHA visits referred to PES (general hospitals) Low 19% 17% 21% 19% High 54% 51% 56% 53% Avg. psychiatric inpatient bed occupancy rate (all hospitals)* 93% 88% 91% 90% Avg. number of psychiatric inpatient beds available per day at 12am census (all hospitals) 17 27 21 22 Avg. psychiatric inpatient bed occupancy rate (gen l hospitals) 91% 88% 90% 90% Avg. number of psychiatric inpatient beds available per day at 12am census (general hospitals) 14 21 16 17 As of January, 10 Occupancy rate is calculated based on Acute Service beds, General Ward beds, and CAMH Schizophrenia beds, but not Short Stay beds As of April, 10 the SHSC Geriatric beds are included in the calculation. ** July-September, 09 information is not available.
Summary snapshot monthly indicators Indicator July 10 August 10 September 10 July-Sept. 10 Avg. occupancy rates by hospital (All hospitals) Low 79% 61% 71% 70% High 97% 96% 97% 97% Number (%) admitted to inpatient bed <3 hrs (from time of Disposition) Number (%) admitted to inpatient bed 3 hrs to 8 hrs (from time of Disposition) Number (%) admitted to inpatient bed >=8 hrs (from time of Disposition) Number (%) admitted to inpatient bed <3 hrs (from time of Patient Initial Triage)* Number (%) admitted to inpatient bed 3 hrs to 8 hrs (from time of Patient Initial Triage)* Number (%) admitted to inpatient bed >=8 hrs (from time of Patient Initial Triage)* 410 (71%) 413 (75%) 414 (72%) 1237 (73% ) 58 (10%) 73 (13%) 67 (12%) 198 (12%) 108 (19%) 63 (11%0 97 (17%) 268 (16%) 88 (15%) 59 (11%) 74 (13%) 221 (13%) 213 (37%) 222 (40%) 235 (41%) 670 (39%) 275 (48%) 268 (49%) 269 (47%) 812 (48%) Avg. wait time from the admission disposition to physical admission to an inpatient bed (general hospitals) Total average 7:40 hrs 4:07 hrs 6:44 hrs 6:11 hrs 95% CI Information is not reported Longest duration waited by a patient (general hospitals) 95:35 hrs 48:55 hrs 72:31 hrs 84:03 hrs Shortest avg. wait time (general hospitals) 3:08 hrs 2:39 hrs 3:17 hrs 3:12 hrs Data is reported as of April, 2010 ** July-September, 09 information is not available.
Mental Health and Addictions Emergency Department (ED)visits percent daily difference from 3 month daily average 150.0% Percent, by hospital and total system, July September, 2010 July August September 100.0% 50.0% % difference 0.0% All hospitals -50.0% -100.0% -150.0% CAMH MSH SHSC SJHC SMH TEGH UHN All hospitals No. of days the system surged* 18 No. of days the system contracted** 21 No. of days the system did not surge/contract 53 *Surge: when mental health and addictions Emergency Department visit volumes per organization are above each organization s monthly average for 5 or more hospitals ** Contraction: when mental health and addictions Emergency Department volumes per organization are less than each organization's monthly average for 5 or more hospitals Source: Decision Support Services; team analysis
Mental Health and Addictions Emergency Department (ED) visits total number of visits per day All Alliance hospitals, July September, 2010 125 July August Period high September 100 Period average 95 Number of visits 75 Period low 50 01-Jul-10 11-Jul-10 21-Jul-10 31-Jul-10 10-Aug-10 20-Aug-10 30-Aug-10 09-Sep-10 19-Sep-10 29-Sep-10 July 26 August 24 September23 Source: Decision Support Services; team analysis July-September, 2010 Total number of MH&A visits to the ED 8,769 Total number of ED visits 107,417 % of MH&A visits of total ED visits 8.2%
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The Flow Map future state vision Future state vision How people enter EDs Once in a TC LHIN ED** How people leave EDs People diverted from EDs through the creation of alternatives in the community in collaboration with community network partners Walks-in alone Comes with/brought by family, friend or neighbour Sent by primary care provider or community psychiatrist Sent by community worker/organization* Accompanied by community worker/ organization* Transferred by acute care/psychiatric hospital Brought by crisis team (community; MCITs) Brought in by police Brought in by EMS Sent/transferred by criminal justice system (corrections facilities/courts) Voluntary Bribed/coerced Involuntary First-time visit Repeat visit Multiple visits to multiple sites SJHC Chose site Did not choose site Ill physical health Physically healthy Safety concerns (for self and/or others) No safety concerns Connected to supports Unconnected TC LHIN resident City of Toronto GTA and beyond CAMH People with mental health and addiction needs feel welcome and well-treated in TC LHIN EDs Reduced wait times and eradication of process- or nonvolume-related delays Consistent quality of service provided no matter who, where or how people access the system MSH Triage (nurse) Registration (worker/nurse) ED team; can include: Nurse Social worker Students Resident(s) (if on) MD Other staff (e.g., security) UHN SMH SHSC Psychiatric Emergency Services team (n/a for MSH; if needed, refer to CAMH); can include: Nurse Social worker Psychiatric assistant Resident(s) (if on) MD Other staff (e.g., security) Consistent, accurate data collection and analysis; on-going system monitoring and improvement action and implementation planning More coordinated approach to training, research and knowledge transfer within and across EDs Replication of leading and evidence-based practices across TC LHIN EDs Replication of leading and evidence-based practices across TC LHIN EDs Enhancement of general ED staff ability to serve people with mental health and addiction needs well Minimization of retelling of story through better information capture/ access and a primary focus on the person s felt need at the given time Variety of mechanisms in place to secure ongoing consumer, family and service provider input Admitted TEGH Legislationadherent sharing of information (subject to consumer consent) Community provider and ED collaboration at the system, organization and individual levels Consistent, reliable, timely connection and supported transition of people from ED to community and vice-versa No bed; wait in ED until bed available or admission no longer needed Right person is admitted to the right bed in a timely manner; eradication of admit-no-bed situations Leave under own volition Without being seen by a physician Against medical advice Discharged Without referral or follow-up appointment Discharged With follow-up appointment within same organization With referral to hospital service provider With referral to community service provider Enhanced capacity to serve people with complex but not acute needs in the community Admitted Minimization of people leaving without being seen Length of inpatient stays based on need rather than resource availability Transferred to bed in same organization Psychiatric Medical Transferred to bed at different organization * For example: social service agency; community mental health agency; addiction treatment organization; long-term care home; school/college/university; community service organization; other organizations ** Excludes The Hospital for Sick Children Source: Team analysis 21
Conclusions 22
COMPLETED OBJECTIVES Now, you have enhanced knowledge of: The City of Toronto s Mental Health and Addictions Emergency Department Alliance (Alliance) Answers to important questions such as : What resources exist within Toronto (Ontario, Canada) Emergency Departments to serve people with mental health and addiction needs? How much are these resources being used? Who is using Toronto Emergency Departments for mental health and addiction needs? How are people moving into, through and out of Toronto Emergency Departments? How were the Health Leaders and MDs engaged? 23
Questions? 24