Transcript Agency: Federation of Organizations

Strategies for Success
NYSOMH Quality Improvement
Initiative
Overview
 Welcome
and Introductions
 Agency Presentations
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
Cardiometabolic Risk: Long Island
Consultation Center
Polypharmacy: Federation of Organizations
 Questions
and Answers
Long Island Consultation
Center
QI Point: Elaine Lederer
Executive Director
Project: Cardiometabolic Risk
Clinic Structure
 Clinic
prescribers: 5 part-time psychiatrists
(shared with OASAS program)
 Medical Director oversees psychiatrists,
but they do not meet as a team.
 Clients see psychiatrist monthly; individual
therapy is weekly.
 Clinic census: 642 (OMH program)
Engagement and Communication
 With
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Medical Director or QI point met with
psychiatrists.
Psychiatrists were receptive to information
about improving prescribing practices.
Reviewed both polypharmacy and
cardiometabolic; chose cardiometabolic.
 With
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prescribers
leadership
QI point reports to the Board of Directors.
Project Structure

Identification of positive cases
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PSYCKES reports were printed by the QI point.
A memo and form were placed in the client’s chart to
be completed by psychiatrist every time a case was
identified.
Clinical review and medication change
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Psychiatrist would discuss options with client.
If switching, psychiatrist would begin a cross-taper.
Clients would be seen bi-weekly (when indicated)
during the cross-taper.
Project Structure (cont.)
 Tracking


and follow-up
QI point would pull chart after a visit to see
completed form.
QI point reviewed all positive cases with
Medical Director at the end of each month.
Tools- Memo to Prescribers
To:
All Psychiatrists
From: Carl Rosenmann, M.D.
Re:
LICC Participation in PSYCKES Program
LICC is participating in the PSYCKES Program CQI initiative on Cardiometabolic Risk.
Basically, patients are identified through Medicaid claims as having been treated for one or several of the
following: hypertension, ischemic vascular disease, hyperlipidemia, obesity, diabetes, or prediabetes AND
who are taking a moderate to high risk (for these conditions) antipsychotic medication.
Our role in this process is simply to try to reduce the risk of cardio metabolic complications by making
efforts to get those identified patients off or to reduce the dosage of high-risk drugs.
For adults (18 and over) these are
For children/adolescents these are
olanzapine, quetiapine, chlorpromazine, thioridazine
all antipsychotic except aripiprazole and ziprasidone
.
We will have developed a clinical review form that should be completed for each identified patient.
Ongoing progress of tapering or rational for not tapering high-risk medications should also be documented on
the form. While this will entail additional paperwork, the number of identified patients is small and should not
be burdensome.
An online educational program is available through PSYCKES about the issues of cardio metabolic
risks of antipsychotic use. I encourage each of you to look at this CME program when available.
Attached is a list of your patients that have been identified. Medicaid claim data associated with
diagnosis and treatment is in their chart. Please complete the attached form for each client at his or her next
appointment.
Tools- Review form for Prescribers
CLINICAL NOTES ON PSYCKES STUDY OF HIGH CARDIO METABOLIC RISK
ANTIPSYCHOTIC USE.
NAME: _______________________________
AGE: ________________________________
MEDICAL RISK FACTORS (BY DIAGNOSIS TREATED):
__________________________________________
__________________________________________
DATE: _____________________________
HIGH/MEDIUM RISK MEDICATION AND DOSAGE:
______________________________________
OTHER MEDICATIONS:
_____________________________________
_____________________________________
_____________________________________
HISTORY OF USE OF MED./HIGH RISK MEDICATION (include diagnosis, target
symptoms, relevant past history of treatment with antipsychotic/mood stabilizers, efforts to
change to alternative lower risk medications)
______________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Integration into Workflow
 Therapists
were aware of project; knew to
look for signs of relapse.
 CQI project was reviewed in supervision
meetings.
 Therapists read psychiatrist notes;
psychiatrists read therapist notes as well.
 Therapists alert psychiatrist to significant
clinical changes via an "alert" form.
Summary
 All
positive cases were reviewed
 Cross-taper is an effective method for
switching medications

Well-received by clients
 Ongoing
monitoring of high-risk patients
 Involved team approach with therapists
 Active follow-up for “no-shows”
Next Steps
 Screen
for positive cases on intake
 Expand to OASAS program
 Expand to non-Medicaid recipients
Federation of Organizations
QI point: Lisa Weiss, LMSW
Corporate Compliance Officer and Director of Quality
Management
Project: Polypharmacy
Clinic Structure
 Clinic
is located within an adult home.
 Clinic Prescriber: 1 psychiatrist, averages
7 hours per week.
 Clients see psychiatrist once every 4-8
weeks (every 6 weeks on average).
 Social Workers and RN’s facilitate group
therapy
 Clinic census: varies between 96-100
Engagement and Communication

With prescribers
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Polypharmacy project was chosen during a
collaborative meeting with the QI point, Chief Medical
Officer (CMO), and psychiatrist.
Prescriber has attended CQI Committee meetings
With leadership
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QI point had support of CMO, CEO, COO.
QI point reports at senior management meetings and
executive meetings; submits monthly reports to the
Board.
Agenda item at monthly Consumer Advisory Board
meetings.
Engagement and Communication
(cont.)
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With staff
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Program Manager discusses CQI Project quarterly at
Provider Meetings (adult home staff and federation
staff).
Regular agenda item at weekly clinic staff meetings.
Clinical case conferences occur on a weekly basis
between prescriber, clinic supervisor, and RN.
Case management staff also receive notice of
medication changes.
With consumers
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Bulletin Board posted at clinic with pertinent CQI
Project information.
Project Structure

Identification of positive cases
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QI point printed reports from PSYCKES for psychiatrist.
QI Team/clerical staff verified data from PSYCKES by creating
excel spreadsheet of all clients with their medication by class;
updated monthly and distributed to team
QI Team/clerical staff conducted chart reviews and reviewed
medication and progress note documentation.
Clinical review
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Psychiatrist and therapist discuss options with the client.
Weekly case conferences between psychiatrist, clinical
supervisor, social worker, and RN.
Psychiatrist documented rationale in the client’s chart if
determined that polypharmacy is necessary.
Project Structure (cont.)

Tracking and follow-up
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QI point reviews positive cases with CMO and
psychiatrist on an ongoing basis.
CQI Committee meets monthly in person or via
conference call and discusses progress and changes
in all positive cases.
CMO and QM Department reviews documentation of
psychiatrist re: medication changes/rationale for such.
Team members assist prescriber with accessing
PSYCKES.
Integration with Workflow

Initially identified positive cases only through
PSYCKES; now, identify additional positive
cases at intake and at time of service planning.
 Created a form for case conferences with
prompts.


See slide.
Amended sheets for physician’s progress notes
with prompts.

See slide.
Tools- Clinical Case Conference
Note
BROOKLYN ADULT CARE CENTER
CLINIC PROGRESS NOTE
CLIENT NAME:
(LAST, FIRST M.I.)
AT
A
CM
CS
CI
DP
Activity Therapy
Assessment
Case Management
Clinical Support
Crisis Intervention
Discharge Planning
HSR
MT
ME
R
RRD
Health Screening/Referral
Medication Therapy
Medication Education
Referral
Rehabilitation Readiness
Development
PRRD
SST
SM
TP
VT
Psych Rehab/Readiness Determination
Support Skill Training
Symptom Management
Treatment Planning
Verbal Therapy
NOTE: Indicate date, service code(s), duration (as appropriate), goal/objective ID for each contact/visit.
Include Signature after each progress note.
DATE Service Duration Goal/ Note:
Codes
Obj.
CS
COLL
Client was subject of Case Conference by interdisciplinary treatment
team. Attendance: ___________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
Psychiatric Issue(s): i.e. non-compliance with:
 Ind VT appointments  Grp VT appointments
 ME/MT appointments  Psychotropic Medications
 other (specify): _____________________
__________________________________________________________
Medical Issue(s): i.e. non-compliance with:
 Medical appointments  Medical Medications  other (specify):
__________________________________________________________
Case Management Issue(s): i.e. non-compliance with:
 Concrete Services (specify): ___________________________________
 budgeting (specify): _________________________________________
 other (specify): _____________________________________________
__________________________________________________________
Adult Home Issue(s): i.e. related to:
 HHA Services (specify): _____________________________________
 House Cleaning (specify): ____________________________________
 financial (specify): __________________________________________
 Other (specify): ____________________________________________
Follow-up: _________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________
date
_________________ __
print
____________________
signature
Tools- Prescriber Progress Note
BROOKLYN ADULT CARE CLINIC
PSYCHIATRIST PROGRESS NOTE
CLIENT NAME:
DATE OF SERVICE:
(LAST, FIRST)
Current Progress & Mental Status Findings Relevant to Target Symptoms:
Current Suicidal/ Homicidal Risk:
Medication:
 Absent
 Present (describe):
 Not Applicable
 Client/Responsible Other understands the need for medication
 Potential Side Effects discussed
 Previously discussed
Side Effects:
 Absent
Medication Change:
 Present (describe):
 No
 Yes (describe):
Assessment/Plan:
Diagnosis Change:
Psychiatrist Signature:
Rev’d 6/23/09
 No
 Yes (describe):
Name (print or stamp):
Date:
Summary
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Used a top-down approach for engagement
Identified a cohort of positive cases via PSYCKES
Intake and service planning time
Team effort to review positive cases
Educated CMO who assisted in engaging prescriber
Team effort to choose indicator
Team meets monthly; prescriber periodically attends; all members to
review PSYCKES data.
Clinical case conferences and chart reviews
Documentation a priority
Developed new forms and tailored existing forms in order to
integrate best practices into routine clinic operations
Results
Next Steps
 Continue
screening for positive cases at
intake and service planning
 Continue to enhance communication
among staff (prescriber, case managers,
QI team, therapists, adult home staff)
 Consider expanding to other OMH
licensed programs
Questions and Answers