A Collaborative Model for Mental
Health Providers
June 2014
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Session Objectives
• Understand key factors influencing the
continuity of care for behavioral health
providers
• Describe a model for collaboration
between mental health providers
• Be able to begin developing a plan for
collaboration to provide a coordinated
care model for patients
Slide 2
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Your Facilitator
SUE KOZLOWSKI
Ms. Kozlowski’s first career was in the Clinical
Laboratory. She has spent the last 12 years facilitating
Lean Six Sigma Process Improvement in all areas of
healthcare, and is the co-author of “Value Stream
Management for Lean Healthcare.” She has also served
as an Examiner for the Michigan Quality Leadership
Award (Michigan Baldrige program).
Ms. Kozlowski earned her Master of Science in Administration in Healthcare
from Central Michigan University and her Bachelor of Science in Medical
Technology from Michigan State University.
She is a Certified Six Sigma Black Belt through the American Society for
Quality, and holds a certification in Lean Healthcare from the University of
Tennessee. She currently services as Director for Healthcare Consulting at
TechSolve, Inc., a not-for-profit lean consulting company.
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Lean Overview
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Lean is…
…a structured problem-solving approach
based on PDCA that harnesses employee
knowledge and buy-in to create and sustain
an improved process.
- Driving value-added process activities that
creates benefit to the customer of the process
- Reducing costs by eliminating wasted effort,
expense, supplies, and space
Doing the right thing…right the first time
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History of Lean Methodology
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The Process in Reality…
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The Process on Paper…
Outcome
Achieved
Every
Time!
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So we become…
The Kings and Queens
Of Work-Arounds
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Process: A Lean Perspective
• Most processes have a significant amount
of waste – in healthcare, as much as 90%
• Waste costs money
• Eliminate waste to reduce costs
Material costs – expired or opened-not-used materials
Hidden costs – extra time and effort
Customer costs – failure to return, service recovery, ‘bad press’
Employee costs – turnover and low morale
Leadership costs – nightmares, ulcers
Organizational costs – margin and market share
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Key Lean Principles
1. Respect for people
2. Elimination of waste
“Non-ValueAdded” or NVA
Activities
“ValueAdded” or VA
Activities
P
A
3. Continuous
incremental
improvement
STD WORK
Time
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D
Performance
C
Lean for Behavioral
Health: Developing a
Collaborative Model
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Transformation Case Study
Prep
Core
Core
Core
Assess
Rapid Improvement
Engagement
Scoping
Strategic
Alignment
Team
Definition
Lean
Training
Value
Stream
Mapping
and
Analysis
Rapid Improvement Events
Coaching
Project Improvements
Mentoring
Steering
Committee
Embed
Daily Kaizen
Sustainment
Coaching & Project Support
Knowledge Transfer
Value Stream and Key Metrics Tracking
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Engagement and Alignment
• Initiation by rural Ohio hospital leaders
− Community benefit
− Six-county coverage area
• Discussions by organization leaders
− Financial pressures
− Quality issues
− Competitiveness as a barrier to quality of
care
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The Current State
• The hospital and four behavioral health
organizations provide inpatient and outpatient
programs; one mental health services board
collects data for the state and provides
oversight
• Continuum of care was fractured
-
Duplicate services provided
Confusion over services provided
Clients “gaming” the system
Market competition
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Pressures
• Recent reimbursement changes
- Data reporting requirements for the state – different
systems with different data
- Service reimbursement changes (for example,
intake assessment)
• Operational costs
- Staffing utilization (Professional and administrative)
- No call / no show rate
• Quality of care / coordination of care issues
• Re-admissions for behavioral health clients
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Behavioral Medicine Value Streams
Ambulatory
Pre-Visit
Prep
Schedule
Visit
Follow-Up
Plan
Transition
to Next
Level of
Care
Outcome Measures: Access; Length of Visit; Cost Per Visit
IP
Transition
from OP /
other
care
Admit
Assess
Treat
Discharge
Transition
to next
level of
care
Outcome Measures: Length of Stay; Cost per Case; Readmissions
ED
Transition
from
other
care
Door
Doc
Dispo
Depart
Outcome Measures: Length of Stay; Cost per Case; Revisits; LWBS
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Transition
to next
level of
care
Where to Begin?
The CEOs of the six organizations took an
amazing step:
They agreed to work together to solve the
problems they were encountering.
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Team Definition
• The CEOs met to discuss the problem.
• The CEOs agreed to bring in an
experienced facilitator from outside the
organizations.
• Front-line staff and leaders would form
the improvement team.
• The CEOs would form the Steering
Committee.
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Lean Assessment
• Visits to the six organizations (Jan 2011)
− Process observations
− Feedback from staff
− Available measures or metrics
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Lean Team Formation
• Steering Committee / Charter (June 2011)
−
−
−
−
−
Report of Assessment Findings
Problem Statement / Project Objective
Metrics
Dates of activities
Team members
• Team education / metrics validation (June
2011)
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Opportunities
• Create a patient-centric model of care
− Improve access
− Continuity of care
• Improve quality of care and reduce costs
• Improve operational efficiencies
− Reduce no call / no show rates
− Understand services and specialties at each
site
• Create a Quality Council
− Collaborative approach
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Lean Project Activities (Jan-Dec)
• Charter meeting, 4 hours (7 members on
the Steering Committee)
• Team education event (14 members on
the Core Team)
• Value Stream Analysis
• Rapid Improvement Events (5)
• Sustainment
• Closure / Celebration
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Lean for Behavioral
Health: Alignment
and Value Stream
Analysis
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Value Stream Analysis
Our project is about helping patients get
more efficient quality care. It’s important
because there are currently a lot of
difficulties for patients in our community.
When we’re done, we’d like to see an
improved experience for clients and staff.
What we’d like to see from you is your
assistance in the process, support, and an
open mind. --Theresa and Elizabeth
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SIPOC
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“Just Do-Its”
A
B
C
D
E
ABC
F
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RIE Topics
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Team Alignment Tool
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Lean for Behavioral
Health: Rapid
Improvement Events
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RIE #1
• Standardized Forms
− Standardized Diagnostic Assessment
• Accomplishments
− Standardized intake form elements
− Electronic version for those sites on an EMR
− Agreement to share the initial intake form
among the organizations
− Communication pathway for sharing / legal
approval and clearance
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RIE #1 – “Aha” Moment
• Representatives from each organization
listed the services they provide
−
−
−
−
−
−
Inpatient
Day Program
Drug and Alcohol
Adults
Teens / Children
Licensed programs
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RIE #2
• Standardized Forms, part 2
Developed draft of “Inpatient
Service Handbook” / review
from legal services
Hospital
Developed revised “Release
of Information Form” for adult
/ adolescent services
For all 6
Developed draft of “Quick
Organizations Reference Referral Form”
with appointment information
area on the back of the trifold brochure
For all 6
Developed draft of “Internal
Organizations Diagnostic/Nursing
Assessment Release Form”
Hospital
Eliminated 12 separate forms requiring a
signature, to a handbook plus one
signature page
Found that existing forms were
inappropriate for the current use
Developed to help clients know where to
go, when being referred among 6 entities
– includes locations & phone numbers
Developed to make release of records
streamlined within the 6 organizations;
formalize sharing documents with respect
to Medicare’s assessment hours cap
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RIE #2, continued
• Standardized Forms
− Other common forms
For
Organizations
with Group
Therapy
For
Organizations
with Group
Developed outline for Group Created to support an increasing need for
Facilitator Training, to include group therapy, and to enhance facilitator
assessment and workshop
skills and comfort level for counselors
For
Organizations
with
Outpatient
Services
Developed a common “No
Call-No Show” policy to
create a similar experience
for clients across all entities
Discussed ideas for pretherapy groups and posttherapy groups
Decided to “park” pre-therapy idea as not
value-added (or reimbursed) effort. For
post-therapy transition, will work with
NAMI to see what similar services are
available
Developed flow chart for no-call, no-show
actions, including increased
communication and tracking (with no
monetary penalties)
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RIE #3
• Community Collaboration
− The six organizations identified over 85
community agencies that interacted
− Representatives from 4 agencies were
invited in to share information
Hope Court: A counselor and one of her clients courageously shared her story
of success
211: 211 Call Center Manager
NAMI: VP and President shared their goals
Hospital Readmission Initiatives: Director of Quality
Anchor Church, “Second Chance” Ministry: Custodian and group leader
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RIE #3, continued
• Community Services Focus
− Youth programs
o School-based
o Other
− Law enforcement
o Handling of suspected “behavioral” issues
o ED interactions
o Communication with primary care-giver
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RIE #3, continued
• From the list of community agencies that
had to be brought together to collaborate,
an idea was born.
“Bridge Builders” is a collaboration of Behavioral
Healthcare Professionals acting as a service
coordination group. For high-utilization, and
frequent-utilization clients, the group would
develop patient-focused, coordinated care plans.
Family and community support and groups would
be incorporated as fully as possible.
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RIE #3, continued
Outcomes would include:
−
−
−
Reduction in hospital admissions and readmissions
Decreased cost of care
Improved treatment outcomes
The objective of the Bridge Builders program is to
demonstrate that a collaborative effort for the
target patient populations will reduce overall costs
and improve outcomes.
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RIE #4
• Access / Transitions of Care
−
−
−
−
−
IP to OP
OP to IP
Crisis situations
Medical emergency situations
Timeliness of access from first contact to first
therapy
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RIE #4, continued
• Example Work Plan: Crisis vs Emergency
Idea
Operational Definition
of Crisis/Emergency
Crisis Communication
What
Develop a standardized clinical definition of
constitutes an emergency and a crisis
Share definition of crisis and emergency with all
referral sources; gain consensus
Crisis Communication Explore alternatives to ER referrals in a crisis
situation
Educate 211 and Other Meet with 211 and others to inform and educate
Referral Sources
about alternative solutions to ED referrals
Educate 211 and Other Make a list of the referral sources to Psych and
Referral Sources
ED for mental health
Service Track for Crisis Identify alternative sources for people in crisis
vs. Emergency
Service Track for Crisis Identify gaps in service for alternative sources
vs. Emergency
Service Track for Crisis Educate referral sources about alternatives e.g.
vs. Emergency
Directory
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Who
When
RIE #5
• Transportation from two perspectives
Transportation – Provider Issues
What
Who
Client no-show/no-call data collection
When
Therapists, Office Staff
Record no-show, cancels, and reschedules
Diana
Gather local transportation options, create list, and create
Brochure/card
Therapist follow up after no-show
Therapist or Clinician
No-show history for patients – “Have you ever missed an
appointment due to transportation issues?”
Phone call, administrative intake, or clinician
Transportation – Patient Issues
What
Who
Call gas stations for discounts or contracts re: discounted gas
vouchers
Call churches for list of pastoral meetings and find out if they
offer any type of transportation assistance
Gather and log information about current transportation
availability
Contact United Way Senior Center regarding new possibilities
for transportation options
ABC
DEF
GHI
JKL
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When
RIE #5: “Aha Moment”
Initial Value Stream:
First
contact
Schedule
Appt
Admin
Assessment
Clinical
Assessment /
Therapy
Check-Out,
documentation,
Billing
Extended Value Stream:
ED Intake &
Discharge
Communication
Crisis Center
Utilization
IOP Intake &
Discharge
Communication
Admission &
Discharge
Communication
Other community stakeholders:
Law
Enforcement
Housing
Services
Spiritual
Care
Community
Transportation
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Other
Community
BH Agencies
Sustainment
• The team developed this definition for the
Quality Council:
− “A multi-disciplinary team focused on
identifying service gaps, providing direction,
and resolving issues related to mental and
behavioral health in our community.”
• Core Team:
− The core team will continue to meet twice
each month during sustainment; then once
each month.
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Metrics: Contact to Therapy
Days From First Contact to First Treatment
25
20
15
10
5
0
6 Entity
Linear (6 Entity)
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Metrics: No-Shows
Assessment No-Shows
40
35
30
25
20
15
10
5
0
6 Entity
Linear (6 Entity)
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Metrics: Time to Physician Appt
Physician Appointment - Days Out
240
220
200
180
160
140
120
100
80
60
40
20
0
6 Entity
Linear (6 Entity)
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Genesis Readmissions
12
11
10
9
8
7
6
5
4
3
2
1
0
IP-Adult
IP-Adol
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Metrics: Readmissions
Readmissions
7
6
5
4
3
2
1
0
Genesis HCS
Linear (Genesis HCS)
Slide 48
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Opportunities – Success?
• Create a patient-centric model of care
− Single point of access
− Reduce delays in setting appointments
• Create collaborative approach between
facilities
• Improve quality of care and reduce costs
− Standard forms
− Standard metrics
Slide 49
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The Six Organizations
• Genesis HealthCare System – Bethesda
Hospital
• Mental Health and Recovery Services
Board
• Tompkins Child and Adolescent Services
• Muskingum Behavioral Health
• Muskingum Valley Health Center
• Six County, Inc.
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Celebration
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Your Opportunities







Complexity of system of care
Amount of coordination between
providers
Incentives to collaborate
Market forces
Helping?
Leadership
Alignment of purpose
Value Stream approach
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Hindering?
Q & A - Discussion
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