PSYCHIATRY SERVICES UPDATE Mark Leary MD, Interim Chief Kathy Ballou RN, Director of Nursing Anton Nigusse Bland MD, PES Medical Director Emily Lee MD, Inpatient Psychiatry Medical Director
TRUE NORTH 2
ZSFG PSYCHIATRY ACUTE & EMERGENCY SERVICES PATIENT FLOW VISION STATEMENT Ensure that our patients will be discharged to the appropriate level of care as soon as they are ready. Maintain access for patients who need the most acute services. 3
BACKGROUND Part of System of Care Owned and operated by the City and County of San Francisco, Department of Public Health (DPH) A component of the San Francisco Health Network (SFHN) Psychiatric services are an integral part of emergency and outpatient network Collaborates closely with DPH and SFHN in providing services 4
BACKGROUND Psychiatric Emergency Services (PES) Only PES in San Francisco > 7,500 encounters/year Psychiatrists and Nurses on-site 24/7 for behavioral health emergencies Emergency assessment Crisis stabilization Transfer to acute inpatient care Referral/linkage to ongoing outpatient care Inpatient Psychiatry Largest acute inpatient service in San Francisco 44 acute admission and acute step-down beds (2 units) Jail Psychiatric Inpatient Unit (8 beds) integrated with Jail Behavioral Health Services 5
PES AND INPATIENT CLINICAL CHALLENGES Serious mental illness (psychosis, high suicide risk) Homelessness (60%) Involuntary treatment (PES 60%, Inpatient 95%) Often unlinked to outpatient treatment despite intensive efforts High levels of substance use disorders Multiple co-morbid medical conditions (dementia, limited ambulation, traumatic brain injury, diabetes) Criminal justice involvement 6
CURRENT CONDITIONS (2018 Jan-May) Psychiatric Emergency Services (PES) 677 encounters/month Median Length of Stay = 13.3 hours Condition Red (diversion) = 11% Outside ER transfer acceptance rate = 73% 7
CURRENT CONDITIONS (2018 Jan-May) Inpatient Psychiatry Acute admissions = 68 patients/month Median Inpatient LOS = 7 days Mean Inpatient LOS = 15 days Length of Stay Range = 1 to 700+ days Readmission rate to inpatient within 30 days of discharge = 3% 8
TARGET AND GOALS No. Targets Baseline 2017 1 By December 2018, 80% of patients surveyed on inpatient psychiatry will indicate satisfaction with services 2 By December 2018, increase percent of acute inpatient care days by 20% 3 By December 2018, reduce PES Condition Red (diversion) by 25% Goal 2018 77% 80% 21% 25% 20% 15% 4 By December 2018, increase completed interfacility transfers from other hospitals to PES by 33% (excludes inappropriate referrals) 30% 40% 9
COUNTERMEASURES No. Root Cause Proposed Countermeasure Outcomes 1 Protracted stays in PES for non-acute patients (1)Pilot for Diversion of ADU Candidates from PES to DUCC (2)Vertical treatment pilot for segmenting flow between high-acuity and low-acuity care needs (3)Redesign of staff workflows to reduce wait times for assessment 516% increase in referrals to DUCC 52% reduction in Condition Red 17% reduction in Length of Stay 10
COUNTERMEASURES (cont.) No. Root Cause Proposed Countermeasure Outcomes 2 Protracted stays on Inpatient Service for non-acute patients (1) Weekly team meetings with DPH Transitions and SF Conservatorship Director to expedite placement of inpatients (2) ZSFG Psychiatry Compliance Committee Documentation Training for Inpatient Staff (3) Implement inpatient administrative day billing by collaborating with DPH, Transitions, UM, and clinical staff (4) DPH Transitions opening of SF Healing Center (St. Mary s) and Hummingbird respite (5) SF Conservator s Office implementation of Post-Acute Community Conservatorship (PACC) + Affidavit B (meds) 29% increase in acute care days Monthly inpatient admissions stable 57% increase in administrative (behavioral) days 11 new PACC conservatorships started on Inpatient (20 overall) 11
OUTCOMES: PES Condition Red % 60% 50% 49% 47% 51% 40% 30% 20% 10% 41% 36% 34% 33% 30% 31% 27% 28% 24% 22% 20% 21% 21% 18% 17% 18% 18% 17% 15% 16% 14% 14% 15% 12% 10% 7% 5% 0% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2016 34% 36% 41% 49% 30% 47% 51% 17% 33% 24% 28% 22% 2017 27% 17% 18% 20% 18% 15% 14% 31% 16% 15% 21% 21% 2018 18% 14% 7% 5% 12% 10% 2016 2017 2018 PES DUCC ADU pilot starts 2018 12
OUTCOMES: PES Median Length of Stay (hours) 18 16 16 14.6 14.5 14 13.3 12 12.3 12 10 8 2018 2017 6 4 2 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec PES DUCC ADU pilot starts 13
OUTCOMES: DUCC Client Referral Sources PES DUCC ADU pilot starts 14
OUTCOMES: Transfers from Outside Hospitals to PES % of patients from outside hospitals (screened appropriate) who were transferred to PES 100% 90% 80% 89% 83% 90% 94% 70% 60% 50% 40% 43% 47% 55% 30% 20% 16% 26% 24% 26% 23% 10% 0% Created 7/18/18 Source: PES e-chart PES DUCC ADU pilot starts 15
INPATIENT OUTCOMES: Acute Day % 100% 90% 80% 70% 60% 50% 40% 30% 24% 21% 27% 22% 20% 18% 17% 10% 14% 24% 20% 23% 22% 24% 28% 29% 29% 29% 19% 0% Created 7/18/17 Source: PES e-chart 16
INPATIENT OUTCOMES: Admissions/month 100 90 80 70 60 50 52 65 55 82 83 68 84 74 72 59 87 64 67 66 59 72 40 30 39 20 10 0 Created 4/2/18 Source: ZSFG data cemter 17
INPATIENT OUTCOMES: Administrative Day % 25% 20% 21% 15% 10% 5% 0% 3% 1% 3% 4% 6% 3% 1% 9% 9% 11% 13% 15% 9% 7% 7% 13% Created 7/18/17 Source: PES e-chart 18
CHALLENGES AND BARRIERS Relative lack of bed resources in continuum of care (hotels, board & care, residential treatment, LSAT beds for high need/risk patients) Relative lack of linkage resources available to PES (especially evenings/weekends), Recruitment and retention of medical providers Recruitment of new Psychiatry Chief 19
ACHIEVEMENTS Launch of Recovery Model practice on inpatient psychiatry to improve patient experience Significant increase in transfer acceptance rate from outside hospitals to PES Implementation of Post-Acute Community Conservatorship (PACC) with SF Conservatorship Office 20
NEXT STEPS Monitor data to measure impact of SF Healing Center (St. Mary s) and Hummingbird Respite Continue active partnership with DPH Transitions and SF Conservator to place challenging patients in the community Continue to Plan-Do-Study-Act countermeasures 21