Psychiatric Flow
Michael Trangle, MD
HealthPartners, Associate Medical Director
Behavioral Health
January 20, 2015
Psychiatric Flow
Michael Trangle, MD
Associate Medical Director
Behavioral Health
Early Data
Fall 2006
3
• 3-month study which involved all Mpls/St.
Paul Metro hospitals with inpatient psychiatric
departments including ED units (ANW,
Fairview, HCMC, North Memorial, Regions, St.
Josephs, United)
• Involved leadership from DHS and all 7 metro
county social services leaders (Ramsey, Anoka,
Hennepin, Scott, Carver, Dakota, Washington).
4
E.D. Patients
• 40-50 patients per month are admitted due to
lack of access to less intensive resources
– 35.3% due to lack of 24 h/d skilled Medical/Behavioral
Nursing services or Intensive Residential Treatment services
– 23% due to lack of substance abuse services (detox, wet bed,
dry bed, CD program with lodging)
– 10% due to lack of access to psychotropic prescriber
5
Metro Inpatient Psych Hospital
Data
• 240-250 patients per month have
“non-acute” days in the hospital
• This totals to 2,000-2,100 “non
acute” days in the hospital per
month
6
– 29.6% of the non-acute bed days were associated with
unavailable beds at AMRTC
– 22.4% of the non-acute bed days were associated with a lack
of Intensive Residential Treatment beds.
– 15% of the non-acute bed days were related to court delays
– 8.5% of the non-acute bed days were attributed to lack of CD
programs with lodging, need for a Rule 25 assessment,
unavailability of sober beds, and need for detoxification
– 8.3% of the non-acute bed days were due to needing 24
hr/day skilled Medical/Behavioral Nursing Services – a
combination of open and locked environments
7
Anoka Metro Treatment Center
(AMTRC) data shows
• 88 patients/month have “non-acute”days
• Total “non acute” days average 1,718 bed
days/months
– About 51% are due to lack of Corporate Foster Care / 24
h/d skilled Behavioral/Medical Services
– About 21% are due to lack of 24 h/d IRTS for complex
behavioral Needs (difficult MI/CD issues)
– About 16% due to lack of housing with services availability
– About 6.2% are due to lack of complex Medical/Behavioral
services
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Conclusions
• Approximately 550 patients per year are admitted from our
metro EDs unnecessarily
• Approximately 45,000 bed days per year are filled with
patients waiting for intermediate resources to become
available
• If we devote adequate resources to intermediate resources
our acute care metro hospitals could potentially treat up to
2,733 more patients per year without adding beds (based
upon LOS of 9 days)
• If we devote adequate resources to intermediate resources
ARTC could potentially treat up to 344 more patients per year
without adding beds (based upon average LOS of 60 days)
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Our Crisis with psychiatric patients being stuck in EDs awaiting
inpatient beds and our shortage of inpatient beds is significantly
due to lack of:
– Housing with supportive services (ranging from a relatively
unskilled person available to talk with and remind patient to
take meds up to facilities with more intensive programming
and ability to manage meds)
– Places for patients with both substance abuse and mental
health problems (with various attached services ranging from
nothing i.e.. sober house to intensive treatment with lodging)
– Inefficiencies built into commitment process
– Facilities able to serve patients with both MH and medical
needs
– Timely access to out patient psychiatry (and other advanced
practice providers)
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• Study also highlights the lack of communication and
coordination between hospitals and community social
services
• Study highlights the need for hospital clinicians and
county social service providers to develop a common
language, sense of responsibility/liability and jointly
create more nuanced services based upon clinical need
instead of traditional ways of bundling and paying for
services.
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Strategies/Efforts to Improve
•
•
•
•
Outpatient
• Access
• DIAMOND/Collaborative Care
• Integrated Care
• MHDAP
• Enhanced Crisis Team
• ACT
• Adult Psychiatric Urgent Care Center/MHCA
Inpatient
• Emergency Departments
• Inpatient Psychiatry – NQA & PADs
• Commitment Process
• Collaborative to Improve Commitment Process
• Regions Efforts
Intermediate Resources
• IRTS/Foster Care/Crisis Beds
• Partial Hospitalization
Transition Efforts
• BH RARE
• In-Reach Social Worker
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Enhanced Crisis Stabilization Team
and Impact
1. Impact of our Mental Health Drug Assistance Program (MHDAP).
MDAP was established in 2008 by the East Metro Mental Health Roundtable to help patients
with mental illnesses and substance use disorders who were unable to get necessary
psychotropic medications. It covers the cost of medications, co-pays, or deductibles for up 3
months (1 month at a time) AND helps eligible patients actually apply and get on insurance
products so they can reliably access meds in the future. Over the years, it has:





Helped 1,404 patients access necessary medications
Spent approximately $207,000 per year
Roughly 15% of patients had insurance
Of the initially uninsured, 72% had insurance (and were able to get meds) when leaving
the program
10% of participants needed help with co-pays, deductibles, or Medicare spend-down/gap
help
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Prior to Starting MHDAP
Hospital Psych
Hospital Physical
Homeless
Employed
In Jail
In Detox/CD Tx
Thoughts Harm Self
Thoughts Harm
Others
Access Free Meds
Missed Meds b/c
Funds
# Participants 1485
17%
4%
14%
20%
6%
8%
22%
16%
23%
58%
At end of MHDAP
(60 days later for most patients)
Hospital Psych
Hospital Physical
Homeless
Employed
In Jail
In Detox/CD Tx
Thoughts Harm Self
Thoughts Harm
Others
Access Free Meds
Missed Meds b/c
Funds
# Participants 368
4%
2%
4%
19%
1%
4%
8%
3%
100%
20%
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15
16
Adult Psychiatric Urgent Care
Satisfaction Survey
17
East Metro Emergency Departments
5. Total behavioral health patient visits in emergency department: 2010-2013
Hospital
2010
2011
2012
2013
2014
Regions –
ER Crisis
Program
6,664
6,903
7,034
7,482
7,550
St. Joseph’s
1,119
1,463
1,424
1,343
-
United
2,113
2,438
3,016
1065
-
Combined
9,664
10,704
11,156
N/A
-
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19
20
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In-Reach Social Worker - Outcomes
Referrals
County of Residence
Regions = 21
Ramsey = 23
St. Joes = 2
Henn = 1
United = 2
Dakota = 1
Housing
At Intake - 40% Homeless or Couch Hopping
At Close - 33% Homeless or Couch Hopping
ER Visits
Total ER Visits 6 months Prior = 306; Avg 12.2
Insurance
16% uninsured at intake
5% uninsured at close
Medical Provider
72% had medical provider at opening
90% had medical provider at closing
Psychiatry
48% had psychiatry at opening
91% had psychiatry at closing
Total ER Visits During In-reach = 95; Avg 3.8
Total ER Visits 6 months post = Data
incomplete, but a dramatic reduction for those
we were able to track
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Non-Qualified Admissions (NQAs)
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Common Reasons for PADs (Regions, 2014
→
→
→
→
→
→
→
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PADs for BH patients - Regions
2009
2010
2011
2012
2013
Jan-July
2014
Number of
PADs
1110
2010
1743
1450
2675
1887
Percentage
of PADs
25%
22.9%
19.0%
15.3%
19.9%
19.7%
Note: This source of hospital data looks at PADs for patients who are insured through
a HealthPartners health plan only. This is roughly 13% of Region’s behavioral health
inpatient population.
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72 Hour Holds from ER Crisis
Program to BH Units
4000
3500
3000
# of admitted pts to
MH units
2500
2000
1500
1000
# of 72 hour holds
500
0
2010
2011
2012
2013
2014 thru Dec
Commitment Process
←
←
←
←
←
←
←
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Hovander House
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Anoka Metro Regional Treatment
Center (AMRTC)
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Reducing Re-Admissions (white
Paper)
http://www.rarereadmissions.org/resources/mental_health.html
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QUESTIONS
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Upcoming RARE Events….
RARE MH Collaborative Final Learning Day
Tuesday February 24, 2015
9:00am – 3:30pm
Maplewood Community Center
2100 White Bear Avenue, Maplewood, MN
Registration now open!
Register here
Future webinars…
To suggest future topics for this series,
Reducing Avoidable Readmissions
Effectively “RARE” Networking
Webinars, contact:
Kathy Cummings, kcummings@icsi.org
Jill Kemper, jkemper@icsi.org