A Day Program is NOT a Day Hospital

1. A Day Program is NOT a Day Hospital Mental Health and Addiction Services Brant Community Healthcare System November 2013

2. Agenda • MH & A Services at the Brant Community Healthcare System in 2009 • Change Catalyst • Goals • Definition • Acute Day Treatment Today • Challenges • Outcomes • Questions

3. Mental Health and Addiction Services in 2009 MH & A Services programs • For Brant, Haldimand, and Norfolk • 24/7 ER nursing consultation, 5 day/week Urgent Care, and Crisis Intervention • 18 bed Psychiatric short-stay stabilization • 5 day/week Day program (0900 – 1430 hours); MH Counselling 5 days/week; and Vocational Program 5 days/week; Med Clinic 5 days/week • None • 5 psychiatrists with priviledges • Community Treatment Order Co-ordinator Making It Happen • Schedule 1 Facility • Crisis Services, including ER • Inpatient Services • Outpatient Services • Day Hospital • Consultation

4. 2009 Outcomes Inpatient • 19% increase in admissions over past 7 years d/t increase psychiatrists and population growth Day Program • Averaged 9 Intakes/month; 7 service initiations/month Vocational Program • Averaged 4 Intakes/month; 3 service initiations/month Lengthy Community Agency waiting lists for support

5. Change Catalysts • In 2010, MH & A Services had to remove $500,000.00 from our budget. Programs that ‘should be in the community’ were the targets. • With the increase in psychiatric admissions, challenges with patient flow were occurring • Outpatient Service was focused on the less acute. Services were unable to assist with the more acute population. • LHIN priorities of reducing/diverting ER MH & A contacts and admissions • Community Agencies would not entertain providing anything more than support.

6. Our Goals • To move our services to Acute Care for both Inpatient and Outpatient programs • To continue to reduce our Inpatient Length of Stay • To enhance patient flow throughout the system • To incorporate the recovery model into our model of care • To create a system that assists with ER and Admission Diversion

7. What is a Day Hospital? Day Hospital is defined as a time-limited, ambulatory, active treatment program that offers therapeutically intensive, coordinated and structured clinical services within a stable therapeutic milieu. The program provides clinical diagnostic and treatment services on a level of intensity equal to an inpatient program, but on less than a 24-hour basis. Day Hospital can be used both as a transitional level of care (i.e., step-down from inpatient) as well as a stand-alone level of care to stabilize a deteriorating condition and avert hospitalization. Treatment needs to focus on the individual's response during treatment program hours, as well as the continuity and transfer of treatment gains during the individual's non-program hours in the home/community.

8. Our Day Hospital – Acute Day Treatment Program • 7 days/week • Clients typically come from 0930 – 1800 hours; staff available to clients from 0830 – 2030 hours • Consulting Psychiatrist that sees clients 5 mornings/week. On-call Psychiatrists are utilized after hours and weekends. • Interdisciplinary team of a Psychiatrist, Nursing, Social Work, Occupational Therapist and Recreation Therapist. Hospital staff rotate through Inpatient and Day Hospital Programs • Clients are admitted (Day Hospital Order Set). Orders are valid for 24 hours. • Unit is set up similar to Inpatient without beds (communication center, group rooms, lounge, kitchen area, interview rooms)

9. Day Hospital - continued • Clients receive individual and group therapy, medication adjustments and monitoring, diagnostic investigation • Clients prepare lunch. This allows us to incorporate budgeting, grocery shopping, food preparation and storage, and clean up into treatment model. Supper is through the hospital meal system. • Addiction Services does provide a group a week. • Follows a Recovery Model. Maximum length of service is 28 days. Individuals may then be admitted to a Middle Recovery Evening Program. • EPI utilizes Day Hospital for more acute cases to divert admission

10. Challenges • Education • A Day Hospital is not a Day Program • Limiting admission access • Changing outpatient culture • Increasing outpatient staff skills to provide service to a more acute population. All disciplines perform MSE and integrate assessment outcome into interventions. • Letting go of the ‘Intake’ mindset • Work hardening to 12 hour tours • Changing community culture • Decrease hospital option for ‘worried well’

11. Admission Sources

12. Outcomes • Continued increase in inpatient admissions since 2009 (14%). 22% of these admissions are <24 hours – which move to Day Hospital • Our Inpatient LOS has gone from 6.8 to 6.54 days • We are currently average 21 admissions/month (target is 19) with 17 service initiations • 22% are from our Crisis (ER and outreach) • 33% are from the Inpatient Unit • 45% are directly from Psychiatrists

15. Outcomes - continued • Average wait time from admission order to assessment is 6.46 hours (this includes off-hour admission orders received) • Average engagement rate of 81% • Average length of service is 18.03 days • Average ER contacts/month is 1.29; average admissions/ month is 1.43