AHP Patient Centered Care Models and Unity Center Psychiatric Emergency Service CHRIS FARENTINOS, MD, MPH VICE PRESIDENT, UNITY CENTER FOR BEHAVIORAL HEALTH 1
Emanuel Medical Center adult behavioral health ED visits Volume during the last 12 months on the chart (October 2014 through September 2015) is up 26% from volume in the first 12 months (April 2012 through March 2013).
Emanuel adult behavioral health ED visits The average minutes per behavioral health ED visit have increased significantly over time, from 629 minutes (10 hours) in first 12 months on the chart to 947 minutes (15.7 hours) on the last 12 months an increase of 50.4%.
On a combined basis, total behavioral health hours are up by 61%. Total hours by facility:
An Introduction to the Challenge 2 million people seek treatment annually in the US for Behavioral Health Care problems in hospital emergency departments at a cost of about $4 billion. ED staff often feel burdened by behavioral health patients. There is much variation in ED expertise and training in mental health problems, which can lead to inadequate care and negative patient and staff experiences. 6 to 12% of all US ED visits are related to psychiatric complaints Strategies for Expediting Psych Admits by J.D. McCourt, MD, Emergency Physicians Monthly February 14, 2011
Boarding in USA Studies showing average psychiatric patient in medical emergency departments boards for an average of between 8 and 34 (!) hours 2012 Harvard study: Psych patients spend an average of 11.5 hours per visit in ED; those waiting for inpatient beds average 15-hour stay 2012 Study: After decision made for psychiatric admission, average adult waits over ten hours in California EDs until transferred
Impact of Boarding Boarding is a costly practice, both financially and medically Average cost to an ED to board a psychiatric patient estimated at $2,264 Psychiatric symptoms of these patients often escalate during boarding in the ED Nicks B, Manthey D. Emerg Med Int. 2012.
Regional Dedicated Emergency Psychiatric Facilities Can accept walk ins and ambulance/police directly Medically unstable patients still have to go to medical ED Considered outpatient service, no need for a bed most programs use recliner chairs Focus is on relieving acute crisis and referral, not comprehensive psychiatric evaluation
We have created a solution...
A UNIQUE COLLABORATION 1 0
Scott Zeller, MD, works as the Chief of Psychiatric Emergency Services for Alameda Health System Psychiatric Emergency Service (PES). He is the past President of the American Association for Emergency Psychiatry and a published author.
Psychiatric Emergency Service PES will have 50 recliners and 8 rooms that can be assigned to calming patients or S&R PES will have the living room low acuity and predischarge Voluntary and involuntary patients Environment designed to reduce agitation Calming architecture and colors to create environment of hope, recovery and hospitality Milieu is kept safe through relationships that are caring and respectful
What is different about our model? Collaboration between four major health systems Community-wide effort (City, counties, payers, EMS, police, mental health and addictions providers) De-criminalization of mental illness remove police from transporting behavioral health patients 24/7 access to psychiatric care Sustainable through Medicaid reimbursement for crisis stabilization CPT code Intentional design for transitions of care Model of hospitality, hope and recovery Peer support specialists part of the skill mix
How did we get here? 16
Production, Preparation, Process = 3 P 17
Unity Vision: Common Themes Grounded on trauma-informed care Relentless vision of wellness Recovery focus No wrong door inclusive and inviting. Low barriers inviting to community, family, visitors Holistic, multidisciplinary therapy designed for unique patients Achieve results/outcomes based. High satisfaction: patients, staff, providers, community Great place to work Shared accountability
Unity Vision: Common Themes Research and education leading evidence based on practice Impacting systems of care (state, national) Continuous learning and discovery Reducing stigma through collaboration and PR Seamless integration and collaboration with: Addictions treatment, homeless services Physical health/pcp Community partners Peer support services
Lean 3P Designing Unity Admissions For four days, a group of healthcare professionals, former patients, county officials, payers, fire bureau, and family members came together in the spirit of respectful listening and inclusiveness to design a place of community healing and hope. The Unity Center for Behavioral Health. Through tours, mapping, and model creation we explored the current state of our behavioral healthcare systems to learn what is working and challenge all assumptions. We agreed upon our collective values and goals as a framework to help address physical, legal, and procedural restraints. Our highly collaborative process provided an opportunity to choose the best ideas and discover new approaches which balance hospitality, safety and respect.
Six Key principles of a trauma-informed approach Safety Trustworthiness and transparency Peer support Collaboration and mutuality Empowerment, voice, choice Cultural, historical and gender issues (SAMHSA)
Unity Big Aims Safety and healing for all, for patients, for families, for staff. It is never okay for a staff person to be injured at work, but we do not have to choose between the safety of the people providing services and the people receiving services. We commit to both. We also do not have to choose between safety and the recovery goals and quality of life of the people receiving services. We commit to both. 24
Transportation Workgroup Co-Chairs: John Custer (Cindy Scherba), Jonathon Jui MD Project Manager: Rick Ralston, Legacy Members: Cindy Scherba (OHSU), Chris Farentinos (Legacy), Herb Ozer (Kaiser), James Mol (Kaiser), David Hidalgo (Mult C. MH), Paul Lewis, MD. (Mult Co.), Darrell Knott (Mult. Co EMS), Marni Storey-Kuyl (Wash Co), Kristen Burke (Wash Co MH), Jonathon Chin (Wash Co EMS), Jill Archer (Clack. Co. MH), Richard Swift (Clack. Co.), Larry MacDaniels (Clack. Co EMS), Mike Marshman (Portland Police), Mary Claire Buckley (Portland Police), Tashia Hager (Portland Police BHU), Ken Burns (Portland Fire EMS), John Nohr (Portland Fire EMS), Jason Rogers (Metro West AMR), Randy Lauer (AMR), Chad Heidt (AMR), Justin Hopkins (OHA/AMH), Terri Schmidt (OHSU) 25
Unity Transitions of Care Workgroup High touch to low touch Colocation In Reach Coordinated Referrals Unaffiliated: Community based partner workflow Affiliated: Community based partner workflow OP Providers doing intake at Unity Identify/inventory services needed Unaffiliated: Peer workflow Affiliated: Peer workflow Bridgers (providers and Peers) Identify gaps Clarify method(s) of access Culturally Specific Technology and Connectivity 7-day Follow up Metric 26
Thank You 37