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
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
2
Case study
• Patient admitted to medical unit for HF with
Depression
3
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
4
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.
5
Defining Mental Illness
6
Percent of US adults with Diagnostic
Behavior Health Criteria
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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
8
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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American health care “gets it right” 54.9% of the time.
Performance Improvement is
“getting it right”
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).
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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
Tools Can Help:
• Measure, assess, diagnose, understand
• Communicate
• Prioritize, make decisions
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Allina Health Improvement Model
Ten Step Quality Improvement Process
1. What do we want
to accomplish?
2. Who are the
stakeholders?
3. How are we doing
it now?
Establish charter & aim
statement
Stakeholder identification
and assessment
Current state description
4. How do we want
to do it in the future?
5. What keeps us
from getting there?
Future or desired state
description
Gap analysis
Identify root causes and
barriers
6. What changes can
we make to get to
the future state?
7. Do it.
8. How did we do?
Test changes
Monitor results,
redesign tests
10. What did we
learn?
Capture lessons learned
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Develop opportunities &
Hypotheses
9. If it worked, can
we do it every time?
Standardize spread
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Gantt chart
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Plan-do-study-act cycle
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Project charter
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Stakeholder analysis
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Affinity diagram
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Benchmarking
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Brainstorming
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Cause-and-effect matrix
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Correlation analysis
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Histogram
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Run chart / Control Chart
Survey
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Fishbone diagram
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The Quality Toolbox; Second Edition, Nancy R. Tague, 2005.
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Work flow diagram
Pareto chart
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Learnings &
Handoff
X
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Changes
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Standardize
& Spread
Flowchart
8
Monitor
X
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Do It
Checklist
5
Root Causes
4
Opportunitie
s
3
Current State
2
Stake-holder
Needs
Tool
1
Charter &
Plans
Tool Matrix
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1. What do we want
to accomplish?
Step 1
Charter and Aim Statement
Establish charter & 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)
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
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
Example: Increase the percent of patients receiving biopsies
the same day as their diagnostic workup from a 2010 Allinawide baseline of 44% to 61% by the end of 2011.
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
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.
2. Who are the
stakeholders?
Stakeholder identification
and assessment
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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Who Cares & What They Care About
A Stakeholder Analysis (Part I)
Stakeholder
Stake in Project
Potential impact on
Project
What is needed from the
Stakeholder?
Power / Interest
Interest: High
Open to Social Work
intervention
Open to appointments/
follow-up being set up
Cooperation in identifying
Providers
Power: High
Referral to Social Work as
needed
Power: High
Patients
Staff Nurses
Physicians/N
P/PA
Nursing
Leadership
Open to intervention
Help to identify patient
with needs
Interest: High
Awareness of process – open
to MH issues being addressed
during medical hospitalization
Power: High
Identify appropriate diagnosis
on active problem list
Interest: Low
Awareness in MH needs
Agreement with process
Interest: High
Stakeholder
Management
Strategy
[See Fig I]
•Better outcomes
•Patient education
•Possible Insurance and
logistical costs
•Family/support
system education
•Social work to take
lead
•More complete
discharge planning for
their patients
•Perception of increased
workload
•Education around
process – follow up
data to keep invested
Assist with engaging
patients in process
Acknowledgement of
•Possible impact on
process. Encouragement
•Education of process
workload
related
to
active
of patients to participate
problem list/patient
Attention to Active
•Follow up data to
identification
Problem list
keep invested
Power: High
Awareness of process
Perceived attitudes
and/or risks of the
Stakeholder?
•Better outcomes for
patients
•Education on process
•Follow up data to
keep invested
Who Cares & What They Care About
A Stakeholder Analysis (Part II)
Stakeholder
Stake in Project
What is needed from the
Stakeholder?
Perceived attitudes
and/or risks of the
Stakeholder?
Stakeholder
Management
Strategy
[See Fig I]
Power: High
Commitment to the
process.
•Better outcome for
patients, more complete
discharge plans
•Education around comorbidities
Interest: High
Identify patients
Increased workload
Knowledge of resources
Training/education
related to MH needs
Collection of data
Training/education of
resources available for MH
Follow up data to
keep invested
Commitment to the
process
Referral to Social Work as
needed.
Better outcome for
patients
Education of process
Potential impact on
Project
Power / Interest
Social
Workers
Clinical Case
Managers
(RN)
Outpatient
Providers
Identifying patients,
meeting with them,
arranging follow-up
Power: Low
Awareness of process
Interest: Low
Follow-up appointments
scheduled
Power: Low
Availability of
appointments
Interest: High
United
Psychiatrist
Power: Low
Awareness of project
Interest: High
Will have better outcomes
for their patients.
Training/education
related to MH needs
Training/education of
resources available
for MH
Nothing at this point
Possible increased volume
Participation in consults
as needed
Better patient outcomes
Perception of increased
workload
Education on process
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:
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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…..
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.
2012 ED Visit Rate by Discharge Department
35%
ED Return Rate
30%
25%
29.1%
25.3%
Better
22.3%
21.0%
20%
14.3%
17.0%
15%
10%
17.3%
13.7%
11.5%
5%
2600 / 4500
30 Day ED Visit Rate
•
30
2600
30 Day ED Visit Rate with Depression Rate
4500
30 Day ED Visit Rate w/o Depression Rate
ED return is counted as a visit to any Allina ED for any reason within 30 days of discharge.
Pre-Intervention Workflow
5. What keeps us
from getting there?
Identify root causes and
barriers
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
32
4. How do we want
to do it in the future?
Future or desired state
description
Gap analysis
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)
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
A. Patient/ Family
A.1. Stigma / Not Reporting
A.2. Finances / Transportation
B. Community Resources
B.1. Lack of available resources
B.2. Transportation
A.3. Level of engagement
A.4. Complexity of healthcare
B.3. Compatible
Appointment Times
(evenings, weekends)
C. Current Processes
C.1. Mental Health Issues not identified
C.2. Consult to Social Work not placed
C.3. Time constraints
C.4. Validity of active problem
C.5. Short Hospitalizations
Mental Health needs not
D.1. Lack of education regarding E.1. Focus on their specialty
sufficiently addressed
Mental Health diagnoses
E.2. Lack of awareness
D.2. Lack of education
regarding Mental Health
F.1. Validity of Problem List
regarding Mental Health
treatment
F.2. Challenges of Documentation
resources
D.3. Workload capacity for
nursing / social work
D. Staff
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F.3. Lack of established data processes
in Epic
E. Physicians
F. Data / Technology
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?
36
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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6. What changes can
we make to get to
the future state?
Develop opportunities &
Hypotheses
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?
38
PI Tools:
Prioritization Matrix
Future State Map
Checklist
RACI Matrix
PDSA
Transition Plan
Communication Plan
Early Stages of Control Planning
Project Plan
Intervention Workflow
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Project Timeline
Improving Transitions for Med/Surg Patients with MH dx
Develop Education/Training
tools for RN staff
Deanne
Develop Education/Training
tools for SW
Diane/Deanne
Implement Communication
tools
Diane/Sairam
Provide Education/Training
Collect/Analyze Data-SW
engagement
Collect/Analyze Data-Follow up
appt
RN leaders for 4500 & Develop education tool for RN's to
2600
know when to put in SW consult
4/29/13
5/13/13
Develop smartphrase to document
SW for 4500 & 2600 decision making; Develop resource 4/29/13
list for follow up appointments
5/13/13
All
Attend staff meetings, hospitalist
meeting, huddles, etc.
5/13/13
6/3/13
All
All
Meet with RN staff to review SW
consult process; Meet with SW staff
to educate process for identifying
5/13/13
patients; implementing decision
making, and arranging follow up
6/3/13
All
SW for 4500 2600
Track data related to SW use of
smartphrase
6/3/13
7/1/13
All
SW for 4500 & 2600
Track data related to follow up
appointments within 14 days
6/3/13
7/1/13
6/3/13
7/1/13
SW for 4500 & 2600;
Communicate progress to all
RN leaders for 4500 &
stakeholders
2600
Communicate ongoing results
All
Analyze final data
All
all
Analyze collected data for pilot
project time period and determine
effectiveness and success towards
outcomes
7/1/13
7/11/13
Complete presentation
All
all
Put project materials together for
Session 4 presentations
7/1/13
7/11/13
Communicate final project results
All
all
Communicate project effectiveness
7/15/13
and outcomes to all stakeholders
Aug-13
All
all
Implement on other units and
other sites as appropriate
Ongoing
Spread project to other
40units/sites
Aug-13
7/29
7/22
7/8
7/15
5/13/13
7/1
Development of newsletter articles,
memo's, and flyers to communicate 4/22/13
to staff about project
Jul-13
6/24
all
6/17
All
6/3
4/29/13
6/10
Development of a decision tree for
those patients who appear on the
4/15/13
report to determine if they are
eligible for program.
Jun-13
5/27
SW for 4500 & 2600
5/20
Sairam
5/6
Develop decision tree for SW
staff
We know that not all patients with
active problems are appropriate.
Who is?
May-13
4/29
All
4/22
Sairam
4/15
4/29/13
Determine "eligible" patients
4/8
4/15/13
Participants
Develop Communication tools
Notes
End Date
Accountable
4/1
Project Step
Apr-13
Start
Date
5/13
Green Text = completed milestone
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
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)
44
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
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
46
Next steps for Integration
47
Resources & Links
•
Tague, N.R. (2005). Quality Toolbox (2005) ASQ Quality Press. Milwakee WI
ISBN-10: 0873896394
•
Institute for Healthcare Improvement (IHI):
•
Wikipedia Quality Tools:
http://www.ihi.org/knowledge/Pages/default.aspx
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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