Transcript Mental Health Demands/Solutions - Spokane Regional Health District

Region 9 Healthcare
Coalition
May 26, 2015
Tamara L. Sheehan, Director of Psychiatry Services
Providence Sacred Heart Medical Center & Children’s Hospital
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The Rundown
Providence Sacred Heart & Children’s Hospital
Psychiatry Service-Line
• Inpatient Departments
– Adult & Geriatric Psychiatry Unit (AGPU) – 18 years and older
– Pediatric Center for Children & Adolescent (PCCA) – 12-18
years
• Outpatient Departments
– Behavioral Education Skills Training (BEST) 5-12 years
– Electroconvulsive Therapy (ECT)
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The Rundown
• Emergency Services
– Psychiatric Emergency Department – 18 years and older
– Emergency Department Psychiatric Triage Department
• Psychiatry Consult Service
– Inpatient Consults
– Outpatient Consults
The Numbers
2014
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AGPU: 12,500 patient days (35 pts/day)
PCCA: 7,500 patient days (21 pts/day)
BEST 16,800 hrs of service (13 pts/day)
ECT: 1,300 hrs of service (6 pts/day)
Adult Psych ED: 230 month
Psych Triage:
– Adult: 425-450 pts month
– Peds: 125-150 month
Current State of Mental Health
• Increased Need for Services
– Everything for everyone
• Gaps in services
– Extremes of:
• Developmentally Delayed & Autistic
• Elderly with dementia/Alzheimer's
• Decreased resources
– Lack of enough & consistent funding
• Decreased appropriate beds
• Lack of providers
Fast Facts of Mental Health
• The U.S. Department of Health and Human Services,
Substance Abuse and Mental Health Services Administration
reports:
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1 in 5 Adults have a diagnosable mental health disorder
Affects all ages, income, religion and cultures.
4 of10 causes of disability.
Treatment improves the lives of 70-90%
2/3rds of those with mental health diagnosis live productive lives
http://store.samhsa.gov/product/Basic-Facts-About-Mental-Health/FAST%20FACT7
What We Are Spending
According to National Association of State Mental Health
Program Directors Research Institute (2004-2010)
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U.S. spends approximately $120.00 per citizen
Washington ranks 21st at $114.00 per citizen
The highest expenditure is $345.00 per citizen in Maine
The Henry J. Kaiser Family Foundation. (2010). Retrieved from http://kff.org/other/stateindicator/smha-expenditures-per-capita/#notes
Inpatient Numbers
Centers for Disease Control National Hospital Discharge Survey
states:
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Psychoses such as major depressive disorders and Schizophrenic
disorders
– Are only second in numbers per thousands to Heart Disease
– Have length of inpatient hospital stays almost 2 times Heart Disease
National Hospital Discharge Survey: 2010 table, Average length of stay and days of care.
(2010, July). Centers for Disease Control, (), . Retrieved from
http://www.cdc.gov/nchs/data/nhds/2average/2010ave2_firstlist.pdf#x2013; Number and rate
of discharges by first-listed diagnostic categories [PDF - 58 KB]</a>
Mental Health Terminology
• Voluntary – Patients volunteering to seek mental health services.
• Involuntary Treatment Act (ITA) – Patients 13 and older who
are deemed gravely disabled, a danger to self or others. Only
designated mental health professionals (DMHP) can enact the ITA (legally
hold people against their will).
• Single Bed Certification (SBC) – Temporarily designating a nonpsychiatric bed as a psychiatric bed.
• Psychiatric Boarding aka Boarding – Placing ITA patients in
non-psychiatric beds, primarily emergency departments, because of
lack of appropriate inpatient psychiatric beds who are waiting for an
inpatient psychiatric bed. .
Washington State Supreme
Court Decision
Detention of D.W., G.K., S.B., E.S., M.H., S.P., L.W., J.P., D.C., and
M.P., Respondents, Franciscan Health Care Systems and Multicare,
Health System, Respondents/Intervenors, v. The Department of Social
and Health Services and Pierce County, Appellants
• What was happening….
– Lengthy boarding of ITA patients
– Treatments varied
Washington State Supreme
Court Decision
• August 7th, 2014 WA State Supreme Court Decision
– Found the ITA authorizes SBC aligned with the statues for recognized
reasons individual to the patient, but not merely because there is a
generalized lack of room at certified facilities
• Effective December, 26th, 2014
• Created & worked under SBC Emergency Rule
– Coordinated between Department of Social and Health Services &
Washington State Hospitals Association
Community Response
• Stakeholders convened
– Spokane County Behavioral Health Organization
– Frontier Behavioral Health (FBH)
• Designated Mental Health Provide (DMHP)
– Spokane Hospital Emergency Departments (ED)
– Spokane County Court
• RSN/FBH & PSHMC represented Eastern Washington in
development of final SBC WAC effective June 2015.
Spokane Community Partner
SBC Goals & Outcome
• Goals
– Maintain patient civil rights
– Provide appropriate care
• Outcome
– Process that maintains civil rights
– Patients are provided care aligned with their mental health
condition
– Extra support provided for all Spokane EDs
………Fast Forward
May 2015
• 2 of 8 psychiatrists resigned positions Jan 2015-May 2015
• No pending arrivals or new applicants
• Resignations of remaining psychiatrists began in May 2015
– All 7 within 10 days
– Effective Sep 5th, 2015
Oh NO!!!
Stages of Disaster
Emergency
Providence Health &
Services Commitment to
our Mission
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Initial Discussions
• Providence Leaned in
– Mental Health Services must continue:
• Was a priority for the Sisters of Providence
• There is a significant community need
• It was the right thing to do
• Question was:
– What do we do to maintain services?
Preparation
Develop Action Plan
• Assigned project manager
• Engage all stakeholders
• Lots of meetings!
Response
Top Priorities
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Re-recruit psychiatrists
Maintain as many services as possible
Prevent ED diversion = keep ED open to ALL patients
Prevent layoffs & keep staff working
Involve, communicate and engage community partners
Supporting non-psychiatry departments, providers &
caregivers
Re-Recruiting Psychiatrists
Immediate Response
• Weekly meetings
– Listen
– Build Trust
– Immediately Lesson workload
• Shifted workloads
• Decreased responsibilities
Maintain Services
Immediate Response
• Hospital Consult Service
• Adult & Adolescent mental health inpatient
services
Functions of the Consult Service
VITAL HOSPTIAL SERVICE
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Medication adjustments & management
Risk/detainment assessments
Legal requirement assessments/Court Needs
Inpatient/Outpatient service's needed
Capacity assessments
Scope of the Consult Service
• 300 initial consults a month
• 200 follow up consults a month
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Adult ED
Pediatric ED
Children's Hospital
Women’s Center
All other medical/Surgical/Critical Care/Telemetry
inpatient beds
• Holy Family
Implementation of Consult
Telepsychiatry
• Within 45 days
– Chose a vendor
• Signed contract….lighting fast!
– Developed processes
• For all points of entry and locations
– Assessed technology gaps
• Purchased and installed equipment
Implementation of Consult
Telepsychiatry, cont.
• Within 45 days, cont.
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Emergently Credentialed & Privileged psychiatrists
Trained telepsychiatrist on Epic
Obtained staff volunteers and trained staff
Engaged and Educated ED physicians, adult and
pediatric Hospitalists
• Telepsych Live
– PSHMC August 3rd
• Implemented 9-12 hrs M-F, 4-8 hrs on weekends
– PHFH September 9th
Maintaining Inpatient
Mental Health Services
• May 25th
– Zero beds versus “some beds”
• July 7th
– Confirmed
• Adolescent beds – 12
• Adult beds – 12
• September 7th, 2015
– AGPU – capacity decreased from 46 to 12
– PCCA – capacity decreased from 24 to 12
Maintaining Services
Creatively Using “empty” Beds
Temporary transition of Psych inpatient beds to medical
beds
• Psych Medical Overflow Created
– PCCA – 6 beds
– AGPU – 14 beds
– Adult & Pediatric Hospitalists managed admitting and
general care
– Epic rebuilt platforms for each area
– Telepsychiatrists managed risk assessments and
medications
• Psychiatric staff provided psychiatric care in overflow
areas
Preventing Layoffs
Mantra: Continue to keep everyone
working during the rebuilding phase
• All staff have collective bargaining agreements
– Must volunteer to work outside their assigned
department
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Had to be the same schedule hours
Had to maintain budgeted hours
Had to volunteer to work outside their unit
Work had to be within their scope of practice
Preventing Layoffs, cont
• Volunteer Positions Created
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Telepresenters
Escorts – For court needs and transporting
ED milieu managers
SBC assessments and coordinators
• Other duties
• Voluntary low census
Community Communication
Immediate Response
Communication was key:
– Engaging Community Partners (My Teammates)
• SCBHO
– Local and regional community partners
• FBH
• Local EDs
• Eastern State Hospital
• Kootenai Behavioral Health
• Emergency Medical Responders
• Local Police
Community Communication
• Provide information
– Situation
– Timely
– Accurate
• Ask for help
– Tactics to help decimate patients
– Tactics to assist with local ED mental health influx
• Ask for patience
• Ask for ideas (AKA – Help)
Psych Department
Communication
• Provide details
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Situation
Timely & Frequent
Accurate
Actions taken is detail
• Plea to their personal mission, as well as Providence
Mission
• Stay encouraging & positive
• Provide a message for future
– Rebuilding, not closing services
Hospital Communication
• Meetings, meetings and more meetings
• Mixture of Psych staff and Community messaging
– Provided by myself
– Provided by Chief Nursing Officer
– Provider by Chief Executive
Recovery
Re-Recruited Psychiatrist
• Final Outcomes – Effective September 7th 2015
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Maintained relieved duties
Revamped work schedules
Patient cap per physician
Incentives for extra work/duties
Recruit, recruit, recruit, work
Maintaining Services
• Consult Service
– Telepsych continues - no longer a short-term solution
– Continually evolving process
– Initial consults completed on over 98% of patients within24
hours of order
• Inpatient Services
– Continue overflow beds until increased capacity
Prevent Layoffs
• No Issues
– Continue to aggressively hire staff
Mitigation
Ongoing Work
• Routine Meetings
– Psychiatrists & Administration
• Gaining feedback
– Unmet needs
– Suggestions
– Opinions
– Administration
• New Issues or status of solutions
• Update on services
• Recruiting updates
• Community Communication Updates
Optimistic Future
• Psychiatry Residency
– 6 more psychiatric beds in August
• 2 signed psychiatrists September arrival
• Continue recruiting process for medical director and
additional adult and pediatric psychiatrists
• Join Venture with Fairfax
– Projected opening 100 inpatient bed facility Q1 2018
• PH&S assessing mental health gaps throughout all
communities
Questions???
Reference
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http://store.samhsa.gov/product/Basic-Facts-About-MentalHealth/FAST%20FACT7
The Henry J. Kaiser Family Foundation. (2010). Retrieved from
http://kff.org/other/state-indicator/smha-expenditures-percapita/#notes
National Hospital Discharge Survey: 2010 table, Average length
of stay and days of care. (2010, July). Centers for Disease
Control, (), . Retrieved from
http://www.cdc.gov/nchs/data/nhds/2average/2010ave2_firstlist.p
df#x2013; Number and rate of discharges by first-listed
diagnostic categories [PDF - 58 KB]</a>
National Association of State Mental Health Program Directors
Research Institute, Inc (NRI), http://www.nri-incdata.org/. Table 1:
SMHA Mental Health Actual Dollar and Per Capita Expenditures
by State (FY2004 - FY2013), accessed May 15, 2015.