The Hospitalized Acute Care Patient with Mental Health Needs

1. The Hospitalized Acute Care Patient with Mental Health Needs November 12, 2013 • Greg Clancy, RN DNP • Performance Improvement Consultant • Allina Performance Resources • Allina Health • Gregory.clancy@allina.com

2. Learning Objectives Discuss how does mental health disorders and impact patients and patient care services Describe how a performance improvement (PI) model can promotes healthcare system change Describe the challenges faced by a PI project to implement Mental Health services for patients on a busy surgical unit Discuss integrated model of care to address challenges of caring for those with physical and mental conditions

3. Case study Patient admitted to medical unit for HF with Depression

4. Terminology Mental Health illness or disorders Behavioral illness or disorders Co morbid conditions: medical and mental conditions Co-occurring disorders: When I use a word” Humpty Dumpty said rather scornful tone, “it means exactly What I want it to mean –neither more or less

5. Patients with Acute Illness and Co-morbid Mental Disorders Unlike many medical disorders patients admitted with a mental health issue cannot be identified by a lab test.

6. Defining Mental Illness

7. Percent of US adults with Diagnostic Behavior Health Criteria

8. Medical Conditions Impact by Co-Morbid Mental Illness Migraine headaches, chronic bronchitis, and back pain About one fifth of patients hospitalized for a heart attack suffer from major depression • Depressed patients also are three times more likely than non-depressed patients to be noncompliant with treatment recommendations

9. Impact of Mental Health Disorders is Prevalent and Substantial

10. Readmission of hospitalized patients with Mental Health Disorder 37 percent of patients with mental illness discharged from acute care hospitals were readmitted within a period of one year, compared with only 27 percent of patients discharged without a mental illness. (Madi, et al., 2007). Heart attack patients who were depressed were more likely to be readmitted in the year after discharge (Frasure-Smith, et al, 200) Patients with severe anxiety had a threefold risk of cardiac related readmission, compared to those without anxiety (Volz, 2010)

11. Mortality Individuals with serious mental illness die, on average, 25 years earlier than the general population

12. American health care “gets it right” 54.9% of the time. Allina Health performance resources is dedicated to improving care for patients and achieving better health and affordability for our communities. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003; 348(26):2635-45 (June 26). Performance Improvement is “getting it right”

13. Allina’s Health Improvement Model “Establishing a Common Language of Improvement is a Key Success Factor.” Institute of Medicine Institute for Healthcare Improvement The Joint Commission

14. Allina Health Improvement Model 10-Step Model Allina Advanced Training Program (AATP) Pedigree Intuitive Problem Solving Process Mutes the debate between: Lean / Six-Sigma / Baldrige Incorporates Key Tools Building Consensus Across Allina

15. When to Use the 10 Steps • Solution unknown or discrepancy between stakeholders about suspected solution • When there is little understanding of current process, data, or customer requirements • When new process / disruption to current process is required

16. Tools are Tools • Tools Can Help: • Measure, assess, diagnose, understand • Communicate • Prioritize, make decisions

17. Allina Health Improvement ModelTen Step Quality Improvement Process 5. What keeps us from getting there? 2. Who are the stakeholders? 3. How are we doing it now? 1. What do we want to accomplish? 4. How do we want to do it in the future? Establish charter & aim statement Future or desired state description Gap analysis Identify root causes and barriers Current state description Stakeholder identification and assessment 6. What changes can we make to get to the future state? Develop opportunities & Hypotheses 7. Do it. 8. How did we do? 9. If it worked, can we do it every time? Test changes Monitor results, redesign tests Standardize spread 10. What did we learn? Capture lessons learned

18. Tool Matrix The Quality Toolbox; Second Edition, Nancy R. Tague, 2005.

19. Step 1Charter and Aim Statement Establish charter & aim statement 1. What do we want to accomplish? • Charter is a “contract” • Clarifies expectations with sponsors • Commits resources • Aligned team members • Identifies project scope • (What’s in and what’s out)

20. Improving Transitions from Medical/Surgical Units for Patients with Mental Health Diagnoses Allina Health Advanced Training Program Cohort 5 July 12, 2013

21. Literature Review • Existing guidelines at Allina Health http://akn.allina.com/patientcare/ • External literature: Evidence Based Practice • Allina Health Library Services will help answer questions, gain knowledge, make more informed decisions

22. SMART Aim Statements • Example: Increase the percent of patients receiving biopsies the same day as their diagnostic workup from a 2010 Allina-wide baseline of 44% to 61% by the end of 2011.

23. Background / Problem Statement • What is the problem? • Why is change needed? • a large number of patients discharging from a Medical/Surgical unit with a Mental Health diagnosis do not currently receive optimal care coordination related to their mental health needs. • How do you really know this is a problem? • Our internal risk tools, Emergency Department return rate, and readmission data identify this as a problem. • What will this project work attempt to solve? • Identify what services are necessary to assure that patients have transition plans that predict success for those patients with Mental Illnesses discharging from Medical/Surgical units. • Evidence of success would include: • Social work involvement during hospitalization • Mental health follow up arranged within 14 days of discharge from a Medical/Surgical unit. • Decreased readmission rates and Emergency Department return rate within 30 days

24. What We Are Trying to Accomplish Aim Statement The aim of the project is to improve transitions of care for patients with mental health comorbidities on stations 2600 and 4500 at United Hospital upon discharge. This will be accomplished by identifying patients with a comorbid medical and mental health diagnosis of depression or anxiety, increasing social service engagement, and ensuring mental health follow up appointments scheduled within 14 days. This will be measured by a comparison of total percentage of patients returned to the Emergency Department within 30 days of discharge.

25. WHO cares and WHAT do they care about? 2. Who are the stakeholders? Stakeholder identification and assessment Identify customers, suppliers, doers, influencers, disruptors, champions Understand their power, influence, requirements and level of support Your team may have the best solution, but it will FAIL without proper stakeholder buy-in

26. Who Cares & What They Care AboutA Stakeholder Analysis (Part I)

27. Who Cares & What They Care AboutA Stakeholder Analysis (Part II)

28. Baseline Data Description • UTD 4500 (General Medicine), UTD 2600 (Surgery) are the test units. These units were selected due to their high volume of discharges and total rate of patients with mental health comorbidities. • Mental Health comorbidities are defined as patients who have Major Depressive Disorder, Depressive Disorder Not Otherwise Specified or Anxiety Disorder and a medical diagnosis. ICD9 Diagnosis Codes (296.xx, 300.xx,311) • We looked for the following information in a chart review to determine need and outcomes: • a social work consult during hospitalization • a mental health plan post discharge • a scheduled outpatient psychiatry appointment post discharge • rate of patients returning to the Emergency Department within 30 days • potentially preventable readmission rate within 30 days

29. Baseline Data Description • Social Work Consult – Was there a social work consult during the visit? • Mental Health Plan – Was there either a preexisting appointment or was one set up during the stay? • Outpatient Psych – Did the patient have an established mental health provider stay? • Even though 4500 does a better job with these metrics…..

30. Baseline Data Description • The ED return rate is much higher among depression patients vs. non-depression ones. • 4500 has a higher ED return rate among both depression and non-depression patients. Better • ED return is counted as a visit to any Allina ED for any reason within 30 days of discharge.

31. Pre-Intervention Workflow

32. What keeps us from getting there? 5. What keeps us from getting there? Identify root causes and barriers • Explore the causes • Leverage data analysis to determine “root causes” and level of importance • Barriers and opportunities • PI Tools: • Fishbone or Cause-and-Effect Matrix • Workflow analysis tools

33. What can we do better? 4. How do we want to do it in the future? Future or desired state description Gap analysis • Review issues that surfaced during steps 1-3 • Research: literature, industry • Document future state requirements / specifications (make sure you have sound measurement system)

34. Positive Deviance Who is doing it better than you are and why is this? How can you emulate the behavior?

35. Barriers To Mental Health Treatment A. Patient/ Family B. Community Resources C. Current Processes C.1. Mental Health Issues not identified B.1. Lack of available resources A.1. Stigma / Not Reporting C.2. Consult to Social Work not placed B.2. Transportation A.2. Finances / Transportation C.3. Time constraints B.3. Compatible Appointment Times (evenings, weekends) A.3. Level of engagement C.4. Validity of active problem A.4. Complexity of healthcare C.5. Short Hospitalizations Mental Health needs not sufficiently addressed D.1. Lack of education regarding Mental Health diagnoses E.1. Focus on their specialty E.2. Lack of awareness regarding Mental Health treatment D.2. Lack of education regarding Mental Health resources F.1. Validity of Problem List F.2. Challenges of Documentation D.3. Workload capacity for nursing / social work F.3. Lack of established data processes in Epic E. Physicians F. Data / Technology D. Staff

36. New Screening Process MENTAL HEALTH SCREENING QUESTIONS (FOR NURSES): Are you having any emotional or mental health problems at present? Have you received any mental health treatment (medications, counseling/therapy) in the past? Do you think you would benefit from receiving mental health services after discharge?

37. New Screening Process MENTAL HEALTH SCREENING QUESTIONS (FOR NURSES): Are you having any emotional or mental health problems at present? Have you received any mental health treatment (medications, counseling/therapy) in the past? Do you think you would benefit from receiving mental health services after discharge?

38. What changes will we make 6. What changes can we make to get to the future state? Develop opportunities & Hypotheses • PI Tools: • Prioritization Matrix • Future State Map • Checklist • RACI Matrix • PDSA • Transition Plan • Communication Plan • Early Stages of Control Planning • Project Plan • Select the best interventions • What do we need to implement to reach our goal? • Define the new process • What does it look like? • Who is going to do what? • Plan the transition • What does it take to implement? • How are we going to lead the change?

39. Intervention Workflow

40. Project Timeline

41. What was the result? Key Variables • Adaptive change takes considerable effort • Changing perspectives of front line providers • Awareness of mental health issues • Technical support with ongoing daily support • Leadership support (informal and formal) • Timing of the service offering Fine tune the data mining process from the problem list

42. Results Part I • UTD Station 4500 (medical) closed, we were only able to evaluate patients on unit 2600 (surgical) • 68 inpatient stays on 2600 resulted in consults to social work • Of those, 65 were from the problem list • 56 (82%) were seen by social work and 42 (62%) had a full assessment • Only 9 (13%) patients opted to have their mental health needs addressed. • Defined as having a future outpatient appointment with a psychiatrist or psychologist

43. Results Part II • Why wasn’t the count higher? (n=68) • Predominantly a surgical unit • Few referrals from Nursing staff • Limited surgeon involvement • Why was opt-in rate so low? (13%) • Reliance on Problem List • Old problem carried forward • Many patients with mental health problems had already established treatment • Patient declined mental health intervention • Dementia was not included in this work

44. What’s “Spread?” The science of taking a local improvement (intervention, idea, process) and disseminating it across a system There are many possible definitions for “a system” (e.g. a hospital, a group of hospitals, a region, a country)

45. Expansion of Project • A successful expansion would require: • A reliable screening method • Increased engagement of all providers • Technical resources available • Adding mental health screening questions to admission flowsheet • Feedback to providers to show benefits • Prioritization of patients seen for greater impact

46. Creating a Culture of Improvement

47. Next steps for Integration

48. Resources & Links Tague, N.R. (2005). Quality Toolbox (2005) ASQ Quality Press. Milwakee WI ISBN-10: 0873896394 Institute for Healthcare Improvement (IHI): http://www.ihi.org/knowledge/Pages/default.aspx Wikipedia Quality Tools: http://en.wikipedia.org/wiki/Six_Sigma#Quality_management_tools_and_methods_used_in_Six_Sigma American Society for Quality: http://asq.org/knowledge-center/index.html(Tools tab) Bush, D.E., et al. (2005). Post-myocardial Infarction Depression. Evidence Report Technology Assessment. Number 123. Rockville, MD: Agency for Healthcare Research and Quality DiMatteo, M.R., Lepper, H.S., and Croghan, T.W. (2000). Depression Is a Risk Factorfor Noncompliance with Medical Treatment: Meta-analysis of the Effects of Anxiety and Depression on Patient Adherence. Archives of Internal Medicine, 160, 2101-2107. National Association of State Mental Health Program Directors. (October 2006). Morbidity and Mortality in People with Serious Mental Illness. Nasrallah, H.A., et al. (2006). Low Rates of Treatment for Hypertension, Dyslipidemia and Diabetes in Schizophrenia: Data from the CATIE Schizophrenia Trial Sample at Baseline. Schizophrenia Research, 86, 15-22 Patten, S. (March 2001). Long-term Medical Conditions and Major Depression in a Canadian Population Study at Waves 1 and 2. Journal of Affective Disorders, 63, 35-41.

49. Questions?? Thank you Greg Clancy, RN DNP Gregory.clancy@allina.com