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Changing Times at CMHI

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Changing Times at CMHI

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    1. Changing Times at CMHI Simrat Sethi, M.D. Interim Clinical Director 2/13/2008 Talk slated to be done by Dr. Sethi …….. I have been at CMHI for 7 years We are in NW part of the state & Serve 41 counties for Adults 56 counties for Children & Adolescents We have 24 locked unit beds, 22 open unit beds and 12 children & Adolescent beds Several Areas of change – some at the central level most changes that we have made in response to the needs of patients Talk slated to be done by Dr. Sethi …….. I have been at CMHI for 7 years We are in NW part of the state & Serve 41 counties for Adults 56 counties for Children & Adolescents We have 24 locked unit beds, 22 open unit beds and 12 children & Adolescent beds Several Areas of change – some at the central level most changes that we have made in response to the needs of patients

    2. CMHI Catchment Area Children/Adolescent (56 counties)

    3. CMHI Catchment Area Adults (41 counties)

    4. Cherokee MHI Reorganization of Children & Adolescent Services Impact of Olmstead Decision Restraint Seclusion Reduction Patient & Employee Injuries from Patient Assault Inpatient Bed Utilization Physician Assistant Psychiatric Education Program

    5. Reorganization of Children &Adolescent Services (2002) Length of Stay Impact on Admissions Greater length of stay = less admissions Less admissions = less quality care Resulting Problem – Admissions were: Community Emergencies Placement of Last Resort -Decrease is in admission/year or total in 2 years -unable to admit community emergencies-Decrease is in admission/year or total in 2 years -unable to admit community emergencies

    6. Reorganization of Children &Adolescent Services(cont.) Solution Re-define Admissions Appropriate 0 – 21 days Questionable 22 < 60 days Inappropriate > 60 days Educate CPC’s, Juvenile Court Officials, Foster Care, Child Protective Programs Using out of state agencies for children who needed longer care Using out of state agencies for children who needed longer care

    7. Reorganization of Children &Adolescent Services(cont.) Result Steady increase in admissions Greater number of appropriate admissions Serving more counties 19 before to over 31 now Average Length of Stay dropped

    8. Children & Adolescent LOS and Admissions

    9. Impact of Olmstead Decision Under ADA persons should be placed in Community if: They do not need institutional level of care Do not wish to remain in institution Goal – Identify Barriers to Discharge Review all patients with longer than 6 month hospital stayReview all patients with longer than 6 month hospital stay

    10. Impact of Olmstead Decision(cont.) Identified Barriers Treatment Resistant Illness Multiple Diagnosis Non-compliance with Treatment Chronic Illness Legal Issues Community Resistance to Placement Multiple Diagnosis on different Axis Legal Issues – Risk to publicMultiple Diagnosis on different Axis Legal Issues – Risk to public

    11. Impact of Olmstead Decision(cont.) Changes Change in Guidelines for Treatment Plans Grand Staffing for Difficult Clinical Situations Relationship with RCF/PMI units Change in Philosophy for Admission Criteria (Reactive to Proactive) Reciprocal Court Orders Change in Guidelines for Treatment Plan – change to active goals and treatment Relationship with RCF/PMI units – improved with exploration of resistance to accepting patients – we will not take them back Change in Philosophy for Admission Criteria – from Reactive to Proactive Reciprocal Court Orders – ex about having to wait hours for court orderChange in Guidelines for Treatment Plan – change to active goals and treatment Relationship with RCF/PMI units – improved with exploration of resistance to accepting patients – we will not take them back Change in Philosophy for Admission Criteria – from Reactive to Proactive Reciprocal Court Orders – ex about having to wait hours for court order

    12. Number of Patients with Length of Stay Greater Than Six Months

    13. Restraint Seclusion Reduction Committee started work in October 2000 Goals of Reducing and eliminating R&S, Enhancing patient and staff safety, Eliminate re-traumatizing patients

    14. Restraint Seclusion Reduction(cont.) Findings: R&S continued till maximum permitted time instead of earliest termination. No pattern to shift, units or staff R&S. Staff Concerns Increase in staff & Patient injury rate “if we do not Seclude or Restrain preemptively” Example about patient’s staying in R or S for upto 4 hours if adult “we still have 1 hour before the order is up”Example about patient’s staying in R or S for upto 4 hours if adult “we still have 1 hour before the order is up”

    15. Interventions Every R&S episode administratively reviewed. Feedback given to staff involved. Training changed from Mandt to Pro-Act. Predicting, preventing and monitoring agitation in patients, skill in de-escalation techniques.

    16. Interventions(cont.) Monthly newsletter for staff. Information on usage, educational information, alternative strategies. Nationwide benchmarks and experience from other facilities.

    17. Interventions(cont.) Sanctuary Model Loosening up of ward rules Availability of phone calls Food and fluids policy Physician availability Social Worker availability Sanctuary Model - Decrease in Trauma re-experience Quiet Room Soft toys Empowering the ward staff to help bring about the change and not feel that they would be penalized for suggesting alternate approaches Social workers are available on the weekend – one day to help with PRP activitiesSanctuary Model - Decrease in Trauma re-experience Quiet Room Soft toys Empowering the ward staff to help bring about the change and not feel that they would be penalized for suggesting alternate approaches Social workers are available on the weekend – one day to help with PRP activities

    18. Restraint/Seclusion Usage

    19. Comparison of Staff Injuries related to Patient Restraint

    20. Results of Staff Injuries related to Patient Restraint

    21. Injuries from Patient Assault New Initiatives Therapeutic Communication Use of Verbal interventions at emergencies Use of Protocols involving patients in the management plan Grand Rounds Cooperation with local law enforcement With the help of PA students and we made a video of case vignettes of actual staff interaction that was considered to be non therapeutic With the help of PA students and we made a video of case vignettes of actual staff interaction that was considered to be non therapeutic

    22. Injuries from Patient Assault(cont.) Improved emergency call system Debriefing after the incident Decrease beds on locked units from 18 –12 Assault on Health Care Worker Class D Felony Reduction of Restraint & Seclusion Anger Management Classes Decrease response time from 2.5 min to less than 30 secsDecrease response time from 2.5 min to less than 30 secs

    23. Injuries from Patient Assault(cont.) “Conventional Wisdom” challenged “Patient assault cannot be prevented” “R&S reduces assaultive behavior” “Mentally ill are not legally responsible for assaults”

    24. Comparison of Staff Injuries related to Patient Assault

    25. Results of Staff Injuries related to Patient Assault

    26. Inpatient Bed Utilization Lack of beds and longer waiting lists Changed from gender specific to co-ed units in Jan 2007 Consulted staff from Clarinda who run a co-ed unit Workgroup of unit staff tackled concerns, rules, logistics

    27. Inpatient Bed Utilization(cont.) Concerns included patient supervision, sexual acting out, disinhibition Consistent access to phone, caffeine, snacks and privileges across the units Direct care staff involvement in planning, problem solving and implementation was key to success.

    28. Adult Patients LOS and Admissions

    29. Physician Assistant Training Program Reason Resources Challenges Recruitment Placement

    30. Reason Lack of physician providers in rural Iowa Cherokee MHI had a previous psychiatry residency program Federal grant obtained.

    31. Resources Staff Psychiatrists Inpatient Units Outpatient Experience at CMHCs On Call Experience Didactics include lectures, case presentations and discussions, observed patient interviewing

    32. Challenges Drying up of federal funds after 2002 Restarting recruitment after obtaining state funding Finding suitable candidates Psychiatrist attrition at the MHI We have lost a clinical director and 2 out 4 psychiatrists this year

    33. Recruitment Physician Assistant conferences Web Site Local Mental Health Provider referrals PA students rotating through the MHI Self referrals from the website

    34. Placement of Graduates Preferred placement in rural Iowa 50% in-of-state placements 3 out 3 recent graduates are working in north west Iowa How do we make rural Iowa an attractive destination for practicing psychiatry?

    35. Future Areas Fall Reduction Suicide Assessment and Prevention How to address? Formal Assessment Communication Environmental Safety

    36. Impact of Changes on Patient Care (cont.) Improved ability to admit by effective bed utilization

    37. Impact of Changes on Patient Care (cont.) Monitoring patient stay and ensuring that patients are discharged to the least restrictive setting.

    38. Impact of Changes on Patient Care (cont.) Positive work environment and ongoing staff training has lead to Decrease in assaults & injuries Work towards the elimination of Restraint & Seclusion Continued building of a team approach

    39. Impact of Changes on Patient Care (cont.) Help ensure good quality psychiatric care by training PA’s/ARNP’s.

    40. Admissions Adult/Children/Adolescent

    41. Average Daily Census Adult/Children/Adolescent

    42. Thank You! The End

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