The Hospitalized Acute Care Patient with Mental Health Needs

November 12, 2013 Greg Clancy, RN DNPPerformance Improvement ConsultantAllina Performance ResourcesAllina Health

Gregory.clancy@allina.com

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

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Case study

• Patient admitted to medical unit for HF with Depression

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Terminology

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When I use a word” Humpty Dumpty said rather scornful tone, “it means exactlyWhat I want it to mean –neither more or less

Mental Health illness or disordersBehavioral illness or disordersCo morbid conditions: medical and mental conditionsCo-occurring disorders:

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.

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Defining Mental Illness

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Percent of US adults with Diagnostic Behavior Health Criteria

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

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Impact of Mental Health Disorders is Prevalent and Substantial

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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)

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Mortality

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

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Performance Improvement is “getting it right”

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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).

Allina Health performance resources is dedicated to improving care for patients and achieving better health and affordability for our communities.

American health care “gets it right” 54.9% of the time.

Allina’s Health Improvement Model

“Establishing a Common Language of Improvement is a Key Success Factor.”

1.Institute of Medicine

2.Institute for Healthcare Improvement

3.The Joint Commission

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Allina Health Improvement Model

10-Step Model

1.Allina Advanced Training Program (AATP) Pedigree

2.Intuitive Problem Solving Process

3.Mutes the debate between: Lean / Six-Sigma / Baldrige

4.Incorporates Key Tools

5.Building Consensus Across Allina

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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

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Tools are Tools

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

6. What changes can we make to get to the future state?

Allina Health Improvement ModelTen Step Quality Improvement Process

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2. Who are the stakeholders?

3. How are we doing it now?

1. What do we want to accomplish?

Establish charter & aim statement

Stakeholder identification and assessment

Current state description

4. How do we want to do it in the future?

Future or desired state descriptionGap analysis

5. What keeps us from getting there?

Identify root causes and barriers

9. If it worked, can we do it every time?

Standardize spread

7. Do it.

Test changes

8. How did we do?

Monitor results, redesign tests

Develop opportunities & Hypotheses

10. What did we learn?

Capture lessons learned

Tool Matrix

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

Step 1Charter and Aim Statement

• Charter is a “contract”• Clarifies expectations with sponsors• Commits resources • Aligned team members • Identifies project scope- (What’s in and what’s out)

1. What do we want to accomplish?

Establish charter & aim statement

Improving Transitions from Medical/Surgical Units for Patients with Mental Health Diagnoses

Allina Health Advanced Training Program

Cohort 5

July 12, 2013

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

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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.

Specific: • Defined population • Outcome metric is clear (not dollars)• Baseline is measured

Measurable: • Statement articulates improvement from numerical baseline to numerical goal• Validated measurement system in place• Measureable verb, usually starts with “Increase”

or “Decrease”

Actionable • Empowers team to create change

Realistic & Relevant • Aligned with strategic goal • Achievable within deadline• Consider a stretch goal (70% chance to get there)

Timely • Has a firm due date

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

What We Are Trying to AccomplishAim 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.

WHO cares and WHAT do they care about?

• 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

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2. Who are the stakeholders?

Stakeholder identification and assessment

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

Potential impact on Project

Stakeholder Management

StrategyPower / Interest [See Fig I]

Power: HighOpen to Social Work

intervention •Better outcomes •Patient education

Interest: HighOpen to appointments/ follow-up being set up

•Possible Insurance and logistical costs

•Family/support system education

Cooperation in identifying Providers

•Social work to take lead

Power: HighReferral to Social Work as

needed

•More complete discharge planning for

their patients

Interest: High Awareness in MH needs •Perception of increased workload

Assist with engaging patients in process

Awareness of process – open to MH issues being addressed during medical hospitalization

Power: HighAcknowledgement of

process. Encouragement of patients to participate

•Education of process

Identify appropriate diagnosis on active problem list

Interest: LowAttention to Active

Problem list •Follow up data to

keep invested

Power: High •Education on process

Interest: High •Follow up data to keep invested

Stakeholder Stake in ProjectWhat is needed from the

Stakeholder?

Perceived attitudes and/or risks of the

Stakeholder?

Patients Open to intervention

Staff NursesHelp to identify patient

with needs

•Education around process – follow up

data to keep invested

Physicians/NP/PA

•Possible impact on workload related to active

problem list/patient identification

Nursing Leadership

Awareness of process Agreement with process •Better outcomes for patients

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

Potential impact on Project

Stakeholder Management

StrategyPower / Interest [See Fig I]

Power: HighCommitment to the

process.

•Better outcome for patients, more complete

discharge plans

•Education around co-morbidities

Interest: High Identify patients Increased workloadTraining/education related to MH needs

Knowledge of resourcesTraining/education related to MH needs

Training/education of resources available

for MH

Collection of dataTraining/education of

resources available for MHFollow up data to

keep invested

Power: LowCommitment to the

process

Interest: LowReferral to Social Work as

needed.

Power: LowWill have better outcomes

for their patients.

Interest: High Possible increased volume

Power: Low Better patient outcomes

Interest: HighPerception of increased

workload

Stakeholder Stake in ProjectWhat is needed from the

Stakeholder?

Perceived attitudes and/or risks of the

Stakeholder?

Education of process

Social Workers

Identifying patients, meeting with them, arranging follow-up

Clinical Case Managers

(RN)Awareness of process

Better outcome for patients

Outpatient Providers

Follow-up appointments scheduled

Availability of appointments

Nothing at this point

United Psychiatrist

Awareness of projectParticipation in consults

as neededEducation on process

Baseline Data Description

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• 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

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…..

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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.

BetterBetter

• ED return is counted as a visit to any Allina ED for any reason within 30 days of discharge.

Pre-Intervention Workflow

What keeps us from getting there?

• 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

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5. What keeps us from getting there?

Identify root causes and barriers

What can we do better?

• Review issues that surfaced during steps 1-3• Research: literature, industry• Document future state requirements / specifications

(make sure you have sound measurement system)

4. How do we want to do it in the future?

Future or desired state descriptionGap analysis

Positive Deviance

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

Barriers To Mental Health Treatment

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A.1. Stigma / Not Reporting

A. Patient/ Family

A.2. Finances / Transportation

A.3. Level of engagement

D. Staff

D.2. Lack of education regarding Mental Health resources

D.3. Workload capacity for nursing / social work

D.1. Lack of education regarding Mental Health diagnoses

B. Community Resources

B.1. Lack of available resources

B.2. Transportation

B.3. Compatible Appointment Times (evenings, weekends)

C.2. Consult to Social Work not placed

C. Current Processes

C.1. Mental Health Issues not identified

C.3. Time constraints

Mental Health needs not sufficiently addressed

Mental Health needs not sufficiently addressed

C.4. Validity of active problem

E.1. Focus on their specialty

E. Physicians

F.1. Validity of Problem List

F. Data / Technology

F.2. Challenges of Documentation

A.4. Complexity of healthcare

E.2. Lack of awarenessregarding Mental Health treatment

C.5. Short Hospitalizations

F.3. Lack of established data processes in Epic

New Screening Process

• MENTAL HEALTH SCREENING QUESTIONS (FOR NURSES):

1.Are you having any emotional or mental health problems at present?

2.Have you received any mental health treatment (medications, counseling/therapy) in the past?

3.Do you think you would benefit from receiving mental health services after discharge?

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New Screening Process

• MENTAL HEALTH SCREENING QUESTIONS (FOR NURSES):

1.Are you having any emotional or mental health problems at present?

2.Have you received any mental health treatment (medications, counseling/therapy) in the past?

3.Do you think you would benefit from receiving mental health services after discharge?

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What changes will we make

• 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?

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6. What changes can we make to get to the future state?

Develop opportunities & Hypotheses

PI Tools:Prioritization MatrixFuture State MapChecklistRACI MatrixPDSATransition PlanCommunication PlanEarly Stages of Control PlanningProject Plan

Intervention Workflow

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Project Timeline

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• 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

Key Variables

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

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

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)

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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

Creating a Culture of Improvement

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From To

• Differing motivations • Collegial support and leveraging strengths of the whole

• Differing approaches • Common language & approach to solving problems (Allina Health Improvement Model)

• Reactive, intuitive work • Proactive use of analytics to predict and prevent issues

• Clearly prioritized work, quantified benefit

• Sustaining the gains, visibility of the performance

• Effectively sharing and spreading the gains

Next steps for Integration

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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.

Questions?? Thank you

•Greg Clancy, RN DNP

Gregory.clancy@allina.com

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