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Examining The Role of the Emergency Department in Reducing Readmissions
Leslie S Zun MD MBA FAAEMPresident Elect American Association
for Emergency Psychiatry Chairman and Professor
Department of Emergency MedicineRFUMSChicago Medical School
Mount Sinai HospitalChicago Illinois
Objectives
How the ED can contribute to reducing readmissions
Review of patient subsets Superusers
Alcoholic
Homeless
Psychiatric
Elderly
Analyze methods that can be used in the ED
What Can We Do
Before patient arrives
During patientrsquos stay
Hospital admissions
After the patient is discharged
Before Patient ArrivesAnalysis of Readmissions
Review of frequent users
Review of frequent readmissions By patient
By diagnoses
By MD
By admitting service or physician
ED Returns with ReadmissionsRising KL et al Emergency department visits after hospital discharge a missing part of the equation Ann Emerge Med 201362145-150
238 returned to ED within 30 days
Older men English speaking
Associated with AMA (5 AMA vs 2 not)
Non-specified chest pain
457 of these were readmitted
CHF highest rate 866
Followed by diabetes complications of device sickle cell
Conclusion - Importance of collaboration with inpatient post acute community based care
Before Patient Arrives Risk Factors for ReadmissionAllandeen N et al Refining readmission risk factors for genera medicine patients J Hosp Med 2011654-60Mudge AM et al Recurrent readmissions in medical patient a prospective study J Hosp Med 2011661-67
Patient types African American
Underweight amp weight loss
Cognitive function
Limited English proficiency
Chronic disease Depression cancer renal failure CHF
Patients taking 6 or more medications
Prior hospitalization in past 6 months
Lifestyle issues Poor and Medicaid
Frequent ED patients
Homeless
Before Patient Arrives Reduce Use
Expand the walk-in and urgent care facilities
Determine which patients have used acute care 3 or more times in the past month
Call these patients to let them know about other resources and link them with health care practitioners case management and disease management
Important role of social workers
Inappropriate Admissions
Legal and liability of sending patients home Secondary utilizes such as police group
homes nursing homes and families Send to acute care to resolve issues
Lack of appropriate assessment Difficulty in contacting PCP Need for collateral information Problem with obtaining old medical records
Lack of outpatient resources Housing Medication Care givers
Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Reliance on Interqual ISSI criteria
Use of admission criteria or guidelines for many conditions
Pneumonia DVT CHF PID asthma
Alternatives to inpatient stay
One Day ReadmissionsPines JM et al Post discharge adverse events for 1-day hospital admissions in older adults admitted from the emergency department Ann Emerge Med 201056253-257
Examined ED readmissions with 1 day stays
121 of all patients
CHF COPD prior hx of CHF
841 patients of 1207 admitted
12 died within 30 days
3 had definitive FU 4 missed FU appointment
Questions
Is it due to premature hospital discharge
Was a one day admission necessary
Alternatives to Inpatient Admission
Observational care
Psychiatric Patients
Acute psychiatric stabilization
Crisis respite
Day hospitals
Living room care
Hospital at Home care
Discharge to Hospital at Home Leff B Defining and disseminating the hospital-at-home model CMAJ 2009 Jan 20180(2)156-7 doi 101503cmaj081891
Have EPs PCPs and home care staff identify patients to benefit from receiving hospital-level care at home
Physician visits at least once daily and 24-hour coverage
Nursing visits once or twice daily
Telehealth nurses providing remote support
Remote monitoring of key health indicators
$1500 less than a comparable inpatient stay
For Admitted Patients Acute Carersquos Role
Start patient in care management
Case management
Social work
Discharge planning
Pharmacy
Occupational and speech therapy
Nutritional service
Identify patients that are at risk for readmission
ED Discharge
Set up follow up appointmentsSharma G et al Outpatient follow-up visits and 30 day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease Arch Intern Med 20101701664-1670
62746 COPD patients 669 had PCP follow up
Patients who follow up visit reduced the risk of an ED visit and readmission
Begin case management Gil M et al Impact of a combined pharmacist and social
worker program to reduce hospital readmission J Mang Care Pharm 201319558-583
Involve social work and pharmacy
Set up home health services
Med reconciliation and FU phone calls
Communicate with PCP Pang PS et al Patients with acute heart failure in the
emergency department do they all need to be admitted J Cardiac Fail 201218900-903
Hand off to primary care
For Discharged PatientsAcute Carersquos Role
Clear detailed discharge plans tailored to patient family clinicians case managers and payers Teach self-care
Improved instructions and instruction process
Patient read back
Encourage self-management
Telehealth technology to monitor at home
Physiciannursesocial worker phone calls
Assign a patient navigator
Value of Patient NavigatorBalaban R et alA randomized controlled trial of a patient navigator intervention in reduce hospital readmissions in a safety new healthcare system CMAR 20133157-158
Role of patient navigator
Support and guidance throughout healthcare continuum
Coordinates appointments
Maintains communications
Arranges interpreter services
Arranges patient transportation
Facilitates linkages to follow up
Study of patient navigators 423 patient navigator and 513 in control
121 were readmitted in patient navigator group and 136 in control group
Super UsersEduardo J LaCalle MD MPH Elaine J Rabin MD and Nicholas G Genes MD PHD HIGH-FREQUENCY USERS OF EMERGENCY DEPARTMENT CARE J Emer Med44 No 6 pp 1167ndash1173 2013
Demographic and utilization characteristics of patients who visit the ED 20 or more times per year
Retrospectively studied patients who visited a large urban ED over a
High-frequency ED users contributing 11 of all visits
More likely to be 30ndash59 years of age (52) insured (81) and have at least one significant psychosocial cofactor (65)
Admission rate was 15
High-frequency users are patients with significant psychiatric and social comorbidities
Effective Interventions for Frequent ED UsersAlthaus E at al Effectiveness of interventions targeting frequent users of emergency department a systematic review Ann Emerg Med 201158 41-52
Reviewed 11 studies
Case management most often studied 7
Demonstrated
Reduced ED use
Reduced cost
Reduced homelessness
Case ManagementRyan P McCormack MD Lily F Hoffman MS Stephen P Wall MD MSc MAEd and Lewis R Goldfrank MD Resource-Limited Collaborative Pilot Intervention for Chronically Homeless Alcohol-Dependent Frequent Emergency Department Users Am J Public Health 2013103S221ndashS224
Case management and homeless outreach to chronically homeless alcohol-dependent frequent emergency department (ED)
The differences between intervention and prospective patients and retrospective controls were ndash121 for ED visits and ndash85 for inpatient days
Eighteen participants accepted shelter no controls were housed
Through intervention ED use decreased and housing was achieved
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Objectives
How the ED can contribute to reducing readmissions
Review of patient subsets Superusers
Alcoholic
Homeless
Psychiatric
Elderly
Analyze methods that can be used in the ED
What Can We Do
Before patient arrives
During patientrsquos stay
Hospital admissions
After the patient is discharged
Before Patient ArrivesAnalysis of Readmissions
Review of frequent users
Review of frequent readmissions By patient
By diagnoses
By MD
By admitting service or physician
ED Returns with ReadmissionsRising KL et al Emergency department visits after hospital discharge a missing part of the equation Ann Emerge Med 201362145-150
238 returned to ED within 30 days
Older men English speaking
Associated with AMA (5 AMA vs 2 not)
Non-specified chest pain
457 of these were readmitted
CHF highest rate 866
Followed by diabetes complications of device sickle cell
Conclusion - Importance of collaboration with inpatient post acute community based care
Before Patient Arrives Risk Factors for ReadmissionAllandeen N et al Refining readmission risk factors for genera medicine patients J Hosp Med 2011654-60Mudge AM et al Recurrent readmissions in medical patient a prospective study J Hosp Med 2011661-67
Patient types African American
Underweight amp weight loss
Cognitive function
Limited English proficiency
Chronic disease Depression cancer renal failure CHF
Patients taking 6 or more medications
Prior hospitalization in past 6 months
Lifestyle issues Poor and Medicaid
Frequent ED patients
Homeless
Before Patient Arrives Reduce Use
Expand the walk-in and urgent care facilities
Determine which patients have used acute care 3 or more times in the past month
Call these patients to let them know about other resources and link them with health care practitioners case management and disease management
Important role of social workers
Inappropriate Admissions
Legal and liability of sending patients home Secondary utilizes such as police group
homes nursing homes and families Send to acute care to resolve issues
Lack of appropriate assessment Difficulty in contacting PCP Need for collateral information Problem with obtaining old medical records
Lack of outpatient resources Housing Medication Care givers
Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Reliance on Interqual ISSI criteria
Use of admission criteria or guidelines for many conditions
Pneumonia DVT CHF PID asthma
Alternatives to inpatient stay
One Day ReadmissionsPines JM et al Post discharge adverse events for 1-day hospital admissions in older adults admitted from the emergency department Ann Emerge Med 201056253-257
Examined ED readmissions with 1 day stays
121 of all patients
CHF COPD prior hx of CHF
841 patients of 1207 admitted
12 died within 30 days
3 had definitive FU 4 missed FU appointment
Questions
Is it due to premature hospital discharge
Was a one day admission necessary
Alternatives to Inpatient Admission
Observational care
Psychiatric Patients
Acute psychiatric stabilization
Crisis respite
Day hospitals
Living room care
Hospital at Home care
Discharge to Hospital at Home Leff B Defining and disseminating the hospital-at-home model CMAJ 2009 Jan 20180(2)156-7 doi 101503cmaj081891
Have EPs PCPs and home care staff identify patients to benefit from receiving hospital-level care at home
Physician visits at least once daily and 24-hour coverage
Nursing visits once or twice daily
Telehealth nurses providing remote support
Remote monitoring of key health indicators
$1500 less than a comparable inpatient stay
For Admitted Patients Acute Carersquos Role
Start patient in care management
Case management
Social work
Discharge planning
Pharmacy
Occupational and speech therapy
Nutritional service
Identify patients that are at risk for readmission
ED Discharge
Set up follow up appointmentsSharma G et al Outpatient follow-up visits and 30 day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease Arch Intern Med 20101701664-1670
62746 COPD patients 669 had PCP follow up
Patients who follow up visit reduced the risk of an ED visit and readmission
Begin case management Gil M et al Impact of a combined pharmacist and social
worker program to reduce hospital readmission J Mang Care Pharm 201319558-583
Involve social work and pharmacy
Set up home health services
Med reconciliation and FU phone calls
Communicate with PCP Pang PS et al Patients with acute heart failure in the
emergency department do they all need to be admitted J Cardiac Fail 201218900-903
Hand off to primary care
For Discharged PatientsAcute Carersquos Role
Clear detailed discharge plans tailored to patient family clinicians case managers and payers Teach self-care
Improved instructions and instruction process
Patient read back
Encourage self-management
Telehealth technology to monitor at home
Physiciannursesocial worker phone calls
Assign a patient navigator
Value of Patient NavigatorBalaban R et alA randomized controlled trial of a patient navigator intervention in reduce hospital readmissions in a safety new healthcare system CMAR 20133157-158
Role of patient navigator
Support and guidance throughout healthcare continuum
Coordinates appointments
Maintains communications
Arranges interpreter services
Arranges patient transportation
Facilitates linkages to follow up
Study of patient navigators 423 patient navigator and 513 in control
121 were readmitted in patient navigator group and 136 in control group
Super UsersEduardo J LaCalle MD MPH Elaine J Rabin MD and Nicholas G Genes MD PHD HIGH-FREQUENCY USERS OF EMERGENCY DEPARTMENT CARE J Emer Med44 No 6 pp 1167ndash1173 2013
Demographic and utilization characteristics of patients who visit the ED 20 or more times per year
Retrospectively studied patients who visited a large urban ED over a
High-frequency ED users contributing 11 of all visits
More likely to be 30ndash59 years of age (52) insured (81) and have at least one significant psychosocial cofactor (65)
Admission rate was 15
High-frequency users are patients with significant psychiatric and social comorbidities
Effective Interventions for Frequent ED UsersAlthaus E at al Effectiveness of interventions targeting frequent users of emergency department a systematic review Ann Emerg Med 201158 41-52
Reviewed 11 studies
Case management most often studied 7
Demonstrated
Reduced ED use
Reduced cost
Reduced homelessness
Case ManagementRyan P McCormack MD Lily F Hoffman MS Stephen P Wall MD MSc MAEd and Lewis R Goldfrank MD Resource-Limited Collaborative Pilot Intervention for Chronically Homeless Alcohol-Dependent Frequent Emergency Department Users Am J Public Health 2013103S221ndashS224
Case management and homeless outreach to chronically homeless alcohol-dependent frequent emergency department (ED)
The differences between intervention and prospective patients and retrospective controls were ndash121 for ED visits and ndash85 for inpatient days
Eighteen participants accepted shelter no controls were housed
Through intervention ED use decreased and housing was achieved
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
What Can We Do
Before patient arrives
During patientrsquos stay
Hospital admissions
After the patient is discharged
Before Patient ArrivesAnalysis of Readmissions
Review of frequent users
Review of frequent readmissions By patient
By diagnoses
By MD
By admitting service or physician
ED Returns with ReadmissionsRising KL et al Emergency department visits after hospital discharge a missing part of the equation Ann Emerge Med 201362145-150
238 returned to ED within 30 days
Older men English speaking
Associated with AMA (5 AMA vs 2 not)
Non-specified chest pain
457 of these were readmitted
CHF highest rate 866
Followed by diabetes complications of device sickle cell
Conclusion - Importance of collaboration with inpatient post acute community based care
Before Patient Arrives Risk Factors for ReadmissionAllandeen N et al Refining readmission risk factors for genera medicine patients J Hosp Med 2011654-60Mudge AM et al Recurrent readmissions in medical patient a prospective study J Hosp Med 2011661-67
Patient types African American
Underweight amp weight loss
Cognitive function
Limited English proficiency
Chronic disease Depression cancer renal failure CHF
Patients taking 6 or more medications
Prior hospitalization in past 6 months
Lifestyle issues Poor and Medicaid
Frequent ED patients
Homeless
Before Patient Arrives Reduce Use
Expand the walk-in and urgent care facilities
Determine which patients have used acute care 3 or more times in the past month
Call these patients to let them know about other resources and link them with health care practitioners case management and disease management
Important role of social workers
Inappropriate Admissions
Legal and liability of sending patients home Secondary utilizes such as police group
homes nursing homes and families Send to acute care to resolve issues
Lack of appropriate assessment Difficulty in contacting PCP Need for collateral information Problem with obtaining old medical records
Lack of outpatient resources Housing Medication Care givers
Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Reliance on Interqual ISSI criteria
Use of admission criteria or guidelines for many conditions
Pneumonia DVT CHF PID asthma
Alternatives to inpatient stay
One Day ReadmissionsPines JM et al Post discharge adverse events for 1-day hospital admissions in older adults admitted from the emergency department Ann Emerge Med 201056253-257
Examined ED readmissions with 1 day stays
121 of all patients
CHF COPD prior hx of CHF
841 patients of 1207 admitted
12 died within 30 days
3 had definitive FU 4 missed FU appointment
Questions
Is it due to premature hospital discharge
Was a one day admission necessary
Alternatives to Inpatient Admission
Observational care
Psychiatric Patients
Acute psychiatric stabilization
Crisis respite
Day hospitals
Living room care
Hospital at Home care
Discharge to Hospital at Home Leff B Defining and disseminating the hospital-at-home model CMAJ 2009 Jan 20180(2)156-7 doi 101503cmaj081891
Have EPs PCPs and home care staff identify patients to benefit from receiving hospital-level care at home
Physician visits at least once daily and 24-hour coverage
Nursing visits once or twice daily
Telehealth nurses providing remote support
Remote monitoring of key health indicators
$1500 less than a comparable inpatient stay
For Admitted Patients Acute Carersquos Role
Start patient in care management
Case management
Social work
Discharge planning
Pharmacy
Occupational and speech therapy
Nutritional service
Identify patients that are at risk for readmission
ED Discharge
Set up follow up appointmentsSharma G et al Outpatient follow-up visits and 30 day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease Arch Intern Med 20101701664-1670
62746 COPD patients 669 had PCP follow up
Patients who follow up visit reduced the risk of an ED visit and readmission
Begin case management Gil M et al Impact of a combined pharmacist and social
worker program to reduce hospital readmission J Mang Care Pharm 201319558-583
Involve social work and pharmacy
Set up home health services
Med reconciliation and FU phone calls
Communicate with PCP Pang PS et al Patients with acute heart failure in the
emergency department do they all need to be admitted J Cardiac Fail 201218900-903
Hand off to primary care
For Discharged PatientsAcute Carersquos Role
Clear detailed discharge plans tailored to patient family clinicians case managers and payers Teach self-care
Improved instructions and instruction process
Patient read back
Encourage self-management
Telehealth technology to monitor at home
Physiciannursesocial worker phone calls
Assign a patient navigator
Value of Patient NavigatorBalaban R et alA randomized controlled trial of a patient navigator intervention in reduce hospital readmissions in a safety new healthcare system CMAR 20133157-158
Role of patient navigator
Support and guidance throughout healthcare continuum
Coordinates appointments
Maintains communications
Arranges interpreter services
Arranges patient transportation
Facilitates linkages to follow up
Study of patient navigators 423 patient navigator and 513 in control
121 were readmitted in patient navigator group and 136 in control group
Super UsersEduardo J LaCalle MD MPH Elaine J Rabin MD and Nicholas G Genes MD PHD HIGH-FREQUENCY USERS OF EMERGENCY DEPARTMENT CARE J Emer Med44 No 6 pp 1167ndash1173 2013
Demographic and utilization characteristics of patients who visit the ED 20 or more times per year
Retrospectively studied patients who visited a large urban ED over a
High-frequency ED users contributing 11 of all visits
More likely to be 30ndash59 years of age (52) insured (81) and have at least one significant psychosocial cofactor (65)
Admission rate was 15
High-frequency users are patients with significant psychiatric and social comorbidities
Effective Interventions for Frequent ED UsersAlthaus E at al Effectiveness of interventions targeting frequent users of emergency department a systematic review Ann Emerg Med 201158 41-52
Reviewed 11 studies
Case management most often studied 7
Demonstrated
Reduced ED use
Reduced cost
Reduced homelessness
Case ManagementRyan P McCormack MD Lily F Hoffman MS Stephen P Wall MD MSc MAEd and Lewis R Goldfrank MD Resource-Limited Collaborative Pilot Intervention for Chronically Homeless Alcohol-Dependent Frequent Emergency Department Users Am J Public Health 2013103S221ndashS224
Case management and homeless outreach to chronically homeless alcohol-dependent frequent emergency department (ED)
The differences between intervention and prospective patients and retrospective controls were ndash121 for ED visits and ndash85 for inpatient days
Eighteen participants accepted shelter no controls were housed
Through intervention ED use decreased and housing was achieved
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Before Patient ArrivesAnalysis of Readmissions
Review of frequent users
Review of frequent readmissions By patient
By diagnoses
By MD
By admitting service or physician
ED Returns with ReadmissionsRising KL et al Emergency department visits after hospital discharge a missing part of the equation Ann Emerge Med 201362145-150
238 returned to ED within 30 days
Older men English speaking
Associated with AMA (5 AMA vs 2 not)
Non-specified chest pain
457 of these were readmitted
CHF highest rate 866
Followed by diabetes complications of device sickle cell
Conclusion - Importance of collaboration with inpatient post acute community based care
Before Patient Arrives Risk Factors for ReadmissionAllandeen N et al Refining readmission risk factors for genera medicine patients J Hosp Med 2011654-60Mudge AM et al Recurrent readmissions in medical patient a prospective study J Hosp Med 2011661-67
Patient types African American
Underweight amp weight loss
Cognitive function
Limited English proficiency
Chronic disease Depression cancer renal failure CHF
Patients taking 6 or more medications
Prior hospitalization in past 6 months
Lifestyle issues Poor and Medicaid
Frequent ED patients
Homeless
Before Patient Arrives Reduce Use
Expand the walk-in and urgent care facilities
Determine which patients have used acute care 3 or more times in the past month
Call these patients to let them know about other resources and link them with health care practitioners case management and disease management
Important role of social workers
Inappropriate Admissions
Legal and liability of sending patients home Secondary utilizes such as police group
homes nursing homes and families Send to acute care to resolve issues
Lack of appropriate assessment Difficulty in contacting PCP Need for collateral information Problem with obtaining old medical records
Lack of outpatient resources Housing Medication Care givers
Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Reliance on Interqual ISSI criteria
Use of admission criteria or guidelines for many conditions
Pneumonia DVT CHF PID asthma
Alternatives to inpatient stay
One Day ReadmissionsPines JM et al Post discharge adverse events for 1-day hospital admissions in older adults admitted from the emergency department Ann Emerge Med 201056253-257
Examined ED readmissions with 1 day stays
121 of all patients
CHF COPD prior hx of CHF
841 patients of 1207 admitted
12 died within 30 days
3 had definitive FU 4 missed FU appointment
Questions
Is it due to premature hospital discharge
Was a one day admission necessary
Alternatives to Inpatient Admission
Observational care
Psychiatric Patients
Acute psychiatric stabilization
Crisis respite
Day hospitals
Living room care
Hospital at Home care
Discharge to Hospital at Home Leff B Defining and disseminating the hospital-at-home model CMAJ 2009 Jan 20180(2)156-7 doi 101503cmaj081891
Have EPs PCPs and home care staff identify patients to benefit from receiving hospital-level care at home
Physician visits at least once daily and 24-hour coverage
Nursing visits once or twice daily
Telehealth nurses providing remote support
Remote monitoring of key health indicators
$1500 less than a comparable inpatient stay
For Admitted Patients Acute Carersquos Role
Start patient in care management
Case management
Social work
Discharge planning
Pharmacy
Occupational and speech therapy
Nutritional service
Identify patients that are at risk for readmission
ED Discharge
Set up follow up appointmentsSharma G et al Outpatient follow-up visits and 30 day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease Arch Intern Med 20101701664-1670
62746 COPD patients 669 had PCP follow up
Patients who follow up visit reduced the risk of an ED visit and readmission
Begin case management Gil M et al Impact of a combined pharmacist and social
worker program to reduce hospital readmission J Mang Care Pharm 201319558-583
Involve social work and pharmacy
Set up home health services
Med reconciliation and FU phone calls
Communicate with PCP Pang PS et al Patients with acute heart failure in the
emergency department do they all need to be admitted J Cardiac Fail 201218900-903
Hand off to primary care
For Discharged PatientsAcute Carersquos Role
Clear detailed discharge plans tailored to patient family clinicians case managers and payers Teach self-care
Improved instructions and instruction process
Patient read back
Encourage self-management
Telehealth technology to monitor at home
Physiciannursesocial worker phone calls
Assign a patient navigator
Value of Patient NavigatorBalaban R et alA randomized controlled trial of a patient navigator intervention in reduce hospital readmissions in a safety new healthcare system CMAR 20133157-158
Role of patient navigator
Support and guidance throughout healthcare continuum
Coordinates appointments
Maintains communications
Arranges interpreter services
Arranges patient transportation
Facilitates linkages to follow up
Study of patient navigators 423 patient navigator and 513 in control
121 were readmitted in patient navigator group and 136 in control group
Super UsersEduardo J LaCalle MD MPH Elaine J Rabin MD and Nicholas G Genes MD PHD HIGH-FREQUENCY USERS OF EMERGENCY DEPARTMENT CARE J Emer Med44 No 6 pp 1167ndash1173 2013
Demographic and utilization characteristics of patients who visit the ED 20 or more times per year
Retrospectively studied patients who visited a large urban ED over a
High-frequency ED users contributing 11 of all visits
More likely to be 30ndash59 years of age (52) insured (81) and have at least one significant psychosocial cofactor (65)
Admission rate was 15
High-frequency users are patients with significant psychiatric and social comorbidities
Effective Interventions for Frequent ED UsersAlthaus E at al Effectiveness of interventions targeting frequent users of emergency department a systematic review Ann Emerg Med 201158 41-52
Reviewed 11 studies
Case management most often studied 7
Demonstrated
Reduced ED use
Reduced cost
Reduced homelessness
Case ManagementRyan P McCormack MD Lily F Hoffman MS Stephen P Wall MD MSc MAEd and Lewis R Goldfrank MD Resource-Limited Collaborative Pilot Intervention for Chronically Homeless Alcohol-Dependent Frequent Emergency Department Users Am J Public Health 2013103S221ndashS224
Case management and homeless outreach to chronically homeless alcohol-dependent frequent emergency department (ED)
The differences between intervention and prospective patients and retrospective controls were ndash121 for ED visits and ndash85 for inpatient days
Eighteen participants accepted shelter no controls were housed
Through intervention ED use decreased and housing was achieved
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
ED Returns with ReadmissionsRising KL et al Emergency department visits after hospital discharge a missing part of the equation Ann Emerge Med 201362145-150
238 returned to ED within 30 days
Older men English speaking
Associated with AMA (5 AMA vs 2 not)
Non-specified chest pain
457 of these were readmitted
CHF highest rate 866
Followed by diabetes complications of device sickle cell
Conclusion - Importance of collaboration with inpatient post acute community based care
Before Patient Arrives Risk Factors for ReadmissionAllandeen N et al Refining readmission risk factors for genera medicine patients J Hosp Med 2011654-60Mudge AM et al Recurrent readmissions in medical patient a prospective study J Hosp Med 2011661-67
Patient types African American
Underweight amp weight loss
Cognitive function
Limited English proficiency
Chronic disease Depression cancer renal failure CHF
Patients taking 6 or more medications
Prior hospitalization in past 6 months
Lifestyle issues Poor and Medicaid
Frequent ED patients
Homeless
Before Patient Arrives Reduce Use
Expand the walk-in and urgent care facilities
Determine which patients have used acute care 3 or more times in the past month
Call these patients to let them know about other resources and link them with health care practitioners case management and disease management
Important role of social workers
Inappropriate Admissions
Legal and liability of sending patients home Secondary utilizes such as police group
homes nursing homes and families Send to acute care to resolve issues
Lack of appropriate assessment Difficulty in contacting PCP Need for collateral information Problem with obtaining old medical records
Lack of outpatient resources Housing Medication Care givers
Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Reliance on Interqual ISSI criteria
Use of admission criteria or guidelines for many conditions
Pneumonia DVT CHF PID asthma
Alternatives to inpatient stay
One Day ReadmissionsPines JM et al Post discharge adverse events for 1-day hospital admissions in older adults admitted from the emergency department Ann Emerge Med 201056253-257
Examined ED readmissions with 1 day stays
121 of all patients
CHF COPD prior hx of CHF
841 patients of 1207 admitted
12 died within 30 days
3 had definitive FU 4 missed FU appointment
Questions
Is it due to premature hospital discharge
Was a one day admission necessary
Alternatives to Inpatient Admission
Observational care
Psychiatric Patients
Acute psychiatric stabilization
Crisis respite
Day hospitals
Living room care
Hospital at Home care
Discharge to Hospital at Home Leff B Defining and disseminating the hospital-at-home model CMAJ 2009 Jan 20180(2)156-7 doi 101503cmaj081891
Have EPs PCPs and home care staff identify patients to benefit from receiving hospital-level care at home
Physician visits at least once daily and 24-hour coverage
Nursing visits once or twice daily
Telehealth nurses providing remote support
Remote monitoring of key health indicators
$1500 less than a comparable inpatient stay
For Admitted Patients Acute Carersquos Role
Start patient in care management
Case management
Social work
Discharge planning
Pharmacy
Occupational and speech therapy
Nutritional service
Identify patients that are at risk for readmission
ED Discharge
Set up follow up appointmentsSharma G et al Outpatient follow-up visits and 30 day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease Arch Intern Med 20101701664-1670
62746 COPD patients 669 had PCP follow up
Patients who follow up visit reduced the risk of an ED visit and readmission
Begin case management Gil M et al Impact of a combined pharmacist and social
worker program to reduce hospital readmission J Mang Care Pharm 201319558-583
Involve social work and pharmacy
Set up home health services
Med reconciliation and FU phone calls
Communicate with PCP Pang PS et al Patients with acute heart failure in the
emergency department do they all need to be admitted J Cardiac Fail 201218900-903
Hand off to primary care
For Discharged PatientsAcute Carersquos Role
Clear detailed discharge plans tailored to patient family clinicians case managers and payers Teach self-care
Improved instructions and instruction process
Patient read back
Encourage self-management
Telehealth technology to monitor at home
Physiciannursesocial worker phone calls
Assign a patient navigator
Value of Patient NavigatorBalaban R et alA randomized controlled trial of a patient navigator intervention in reduce hospital readmissions in a safety new healthcare system CMAR 20133157-158
Role of patient navigator
Support and guidance throughout healthcare continuum
Coordinates appointments
Maintains communications
Arranges interpreter services
Arranges patient transportation
Facilitates linkages to follow up
Study of patient navigators 423 patient navigator and 513 in control
121 were readmitted in patient navigator group and 136 in control group
Super UsersEduardo J LaCalle MD MPH Elaine J Rabin MD and Nicholas G Genes MD PHD HIGH-FREQUENCY USERS OF EMERGENCY DEPARTMENT CARE J Emer Med44 No 6 pp 1167ndash1173 2013
Demographic and utilization characteristics of patients who visit the ED 20 or more times per year
Retrospectively studied patients who visited a large urban ED over a
High-frequency ED users contributing 11 of all visits
More likely to be 30ndash59 years of age (52) insured (81) and have at least one significant psychosocial cofactor (65)
Admission rate was 15
High-frequency users are patients with significant psychiatric and social comorbidities
Effective Interventions for Frequent ED UsersAlthaus E at al Effectiveness of interventions targeting frequent users of emergency department a systematic review Ann Emerg Med 201158 41-52
Reviewed 11 studies
Case management most often studied 7
Demonstrated
Reduced ED use
Reduced cost
Reduced homelessness
Case ManagementRyan P McCormack MD Lily F Hoffman MS Stephen P Wall MD MSc MAEd and Lewis R Goldfrank MD Resource-Limited Collaborative Pilot Intervention for Chronically Homeless Alcohol-Dependent Frequent Emergency Department Users Am J Public Health 2013103S221ndashS224
Case management and homeless outreach to chronically homeless alcohol-dependent frequent emergency department (ED)
The differences between intervention and prospective patients and retrospective controls were ndash121 for ED visits and ndash85 for inpatient days
Eighteen participants accepted shelter no controls were housed
Through intervention ED use decreased and housing was achieved
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Before Patient Arrives Risk Factors for ReadmissionAllandeen N et al Refining readmission risk factors for genera medicine patients J Hosp Med 2011654-60Mudge AM et al Recurrent readmissions in medical patient a prospective study J Hosp Med 2011661-67
Patient types African American
Underweight amp weight loss
Cognitive function
Limited English proficiency
Chronic disease Depression cancer renal failure CHF
Patients taking 6 or more medications
Prior hospitalization in past 6 months
Lifestyle issues Poor and Medicaid
Frequent ED patients
Homeless
Before Patient Arrives Reduce Use
Expand the walk-in and urgent care facilities
Determine which patients have used acute care 3 or more times in the past month
Call these patients to let them know about other resources and link them with health care practitioners case management and disease management
Important role of social workers
Inappropriate Admissions
Legal and liability of sending patients home Secondary utilizes such as police group
homes nursing homes and families Send to acute care to resolve issues
Lack of appropriate assessment Difficulty in contacting PCP Need for collateral information Problem with obtaining old medical records
Lack of outpatient resources Housing Medication Care givers
Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Reliance on Interqual ISSI criteria
Use of admission criteria or guidelines for many conditions
Pneumonia DVT CHF PID asthma
Alternatives to inpatient stay
One Day ReadmissionsPines JM et al Post discharge adverse events for 1-day hospital admissions in older adults admitted from the emergency department Ann Emerge Med 201056253-257
Examined ED readmissions with 1 day stays
121 of all patients
CHF COPD prior hx of CHF
841 patients of 1207 admitted
12 died within 30 days
3 had definitive FU 4 missed FU appointment
Questions
Is it due to premature hospital discharge
Was a one day admission necessary
Alternatives to Inpatient Admission
Observational care
Psychiatric Patients
Acute psychiatric stabilization
Crisis respite
Day hospitals
Living room care
Hospital at Home care
Discharge to Hospital at Home Leff B Defining and disseminating the hospital-at-home model CMAJ 2009 Jan 20180(2)156-7 doi 101503cmaj081891
Have EPs PCPs and home care staff identify patients to benefit from receiving hospital-level care at home
Physician visits at least once daily and 24-hour coverage
Nursing visits once or twice daily
Telehealth nurses providing remote support
Remote monitoring of key health indicators
$1500 less than a comparable inpatient stay
For Admitted Patients Acute Carersquos Role
Start patient in care management
Case management
Social work
Discharge planning
Pharmacy
Occupational and speech therapy
Nutritional service
Identify patients that are at risk for readmission
ED Discharge
Set up follow up appointmentsSharma G et al Outpatient follow-up visits and 30 day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease Arch Intern Med 20101701664-1670
62746 COPD patients 669 had PCP follow up
Patients who follow up visit reduced the risk of an ED visit and readmission
Begin case management Gil M et al Impact of a combined pharmacist and social
worker program to reduce hospital readmission J Mang Care Pharm 201319558-583
Involve social work and pharmacy
Set up home health services
Med reconciliation and FU phone calls
Communicate with PCP Pang PS et al Patients with acute heart failure in the
emergency department do they all need to be admitted J Cardiac Fail 201218900-903
Hand off to primary care
For Discharged PatientsAcute Carersquos Role
Clear detailed discharge plans tailored to patient family clinicians case managers and payers Teach self-care
Improved instructions and instruction process
Patient read back
Encourage self-management
Telehealth technology to monitor at home
Physiciannursesocial worker phone calls
Assign a patient navigator
Value of Patient NavigatorBalaban R et alA randomized controlled trial of a patient navigator intervention in reduce hospital readmissions in a safety new healthcare system CMAR 20133157-158
Role of patient navigator
Support and guidance throughout healthcare continuum
Coordinates appointments
Maintains communications
Arranges interpreter services
Arranges patient transportation
Facilitates linkages to follow up
Study of patient navigators 423 patient navigator and 513 in control
121 were readmitted in patient navigator group and 136 in control group
Super UsersEduardo J LaCalle MD MPH Elaine J Rabin MD and Nicholas G Genes MD PHD HIGH-FREQUENCY USERS OF EMERGENCY DEPARTMENT CARE J Emer Med44 No 6 pp 1167ndash1173 2013
Demographic and utilization characteristics of patients who visit the ED 20 or more times per year
Retrospectively studied patients who visited a large urban ED over a
High-frequency ED users contributing 11 of all visits
More likely to be 30ndash59 years of age (52) insured (81) and have at least one significant psychosocial cofactor (65)
Admission rate was 15
High-frequency users are patients with significant psychiatric and social comorbidities
Effective Interventions for Frequent ED UsersAlthaus E at al Effectiveness of interventions targeting frequent users of emergency department a systematic review Ann Emerg Med 201158 41-52
Reviewed 11 studies
Case management most often studied 7
Demonstrated
Reduced ED use
Reduced cost
Reduced homelessness
Case ManagementRyan P McCormack MD Lily F Hoffman MS Stephen P Wall MD MSc MAEd and Lewis R Goldfrank MD Resource-Limited Collaborative Pilot Intervention for Chronically Homeless Alcohol-Dependent Frequent Emergency Department Users Am J Public Health 2013103S221ndashS224
Case management and homeless outreach to chronically homeless alcohol-dependent frequent emergency department (ED)
The differences between intervention and prospective patients and retrospective controls were ndash121 for ED visits and ndash85 for inpatient days
Eighteen participants accepted shelter no controls were housed
Through intervention ED use decreased and housing was achieved
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Before Patient Arrives Reduce Use
Expand the walk-in and urgent care facilities
Determine which patients have used acute care 3 or more times in the past month
Call these patients to let them know about other resources and link them with health care practitioners case management and disease management
Important role of social workers
Inappropriate Admissions
Legal and liability of sending patients home Secondary utilizes such as police group
homes nursing homes and families Send to acute care to resolve issues
Lack of appropriate assessment Difficulty in contacting PCP Need for collateral information Problem with obtaining old medical records
Lack of outpatient resources Housing Medication Care givers
Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Reliance on Interqual ISSI criteria
Use of admission criteria or guidelines for many conditions
Pneumonia DVT CHF PID asthma
Alternatives to inpatient stay
One Day ReadmissionsPines JM et al Post discharge adverse events for 1-day hospital admissions in older adults admitted from the emergency department Ann Emerge Med 201056253-257
Examined ED readmissions with 1 day stays
121 of all patients
CHF COPD prior hx of CHF
841 patients of 1207 admitted
12 died within 30 days
3 had definitive FU 4 missed FU appointment
Questions
Is it due to premature hospital discharge
Was a one day admission necessary
Alternatives to Inpatient Admission
Observational care
Psychiatric Patients
Acute psychiatric stabilization
Crisis respite
Day hospitals
Living room care
Hospital at Home care
Discharge to Hospital at Home Leff B Defining and disseminating the hospital-at-home model CMAJ 2009 Jan 20180(2)156-7 doi 101503cmaj081891
Have EPs PCPs and home care staff identify patients to benefit from receiving hospital-level care at home
Physician visits at least once daily and 24-hour coverage
Nursing visits once or twice daily
Telehealth nurses providing remote support
Remote monitoring of key health indicators
$1500 less than a comparable inpatient stay
For Admitted Patients Acute Carersquos Role
Start patient in care management
Case management
Social work
Discharge planning
Pharmacy
Occupational and speech therapy
Nutritional service
Identify patients that are at risk for readmission
ED Discharge
Set up follow up appointmentsSharma G et al Outpatient follow-up visits and 30 day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease Arch Intern Med 20101701664-1670
62746 COPD patients 669 had PCP follow up
Patients who follow up visit reduced the risk of an ED visit and readmission
Begin case management Gil M et al Impact of a combined pharmacist and social
worker program to reduce hospital readmission J Mang Care Pharm 201319558-583
Involve social work and pharmacy
Set up home health services
Med reconciliation and FU phone calls
Communicate with PCP Pang PS et al Patients with acute heart failure in the
emergency department do they all need to be admitted J Cardiac Fail 201218900-903
Hand off to primary care
For Discharged PatientsAcute Carersquos Role
Clear detailed discharge plans tailored to patient family clinicians case managers and payers Teach self-care
Improved instructions and instruction process
Patient read back
Encourage self-management
Telehealth technology to monitor at home
Physiciannursesocial worker phone calls
Assign a patient navigator
Value of Patient NavigatorBalaban R et alA randomized controlled trial of a patient navigator intervention in reduce hospital readmissions in a safety new healthcare system CMAR 20133157-158
Role of patient navigator
Support and guidance throughout healthcare continuum
Coordinates appointments
Maintains communications
Arranges interpreter services
Arranges patient transportation
Facilitates linkages to follow up
Study of patient navigators 423 patient navigator and 513 in control
121 were readmitted in patient navigator group and 136 in control group
Super UsersEduardo J LaCalle MD MPH Elaine J Rabin MD and Nicholas G Genes MD PHD HIGH-FREQUENCY USERS OF EMERGENCY DEPARTMENT CARE J Emer Med44 No 6 pp 1167ndash1173 2013
Demographic and utilization characteristics of patients who visit the ED 20 or more times per year
Retrospectively studied patients who visited a large urban ED over a
High-frequency ED users contributing 11 of all visits
More likely to be 30ndash59 years of age (52) insured (81) and have at least one significant psychosocial cofactor (65)
Admission rate was 15
High-frequency users are patients with significant psychiatric and social comorbidities
Effective Interventions for Frequent ED UsersAlthaus E at al Effectiveness of interventions targeting frequent users of emergency department a systematic review Ann Emerg Med 201158 41-52
Reviewed 11 studies
Case management most often studied 7
Demonstrated
Reduced ED use
Reduced cost
Reduced homelessness
Case ManagementRyan P McCormack MD Lily F Hoffman MS Stephen P Wall MD MSc MAEd and Lewis R Goldfrank MD Resource-Limited Collaborative Pilot Intervention for Chronically Homeless Alcohol-Dependent Frequent Emergency Department Users Am J Public Health 2013103S221ndashS224
Case management and homeless outreach to chronically homeless alcohol-dependent frequent emergency department (ED)
The differences between intervention and prospective patients and retrospective controls were ndash121 for ED visits and ndash85 for inpatient days
Eighteen participants accepted shelter no controls were housed
Through intervention ED use decreased and housing was achieved
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Inappropriate Admissions
Legal and liability of sending patients home Secondary utilizes such as police group
homes nursing homes and families Send to acute care to resolve issues
Lack of appropriate assessment Difficulty in contacting PCP Need for collateral information Problem with obtaining old medical records
Lack of outpatient resources Housing Medication Care givers
Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Reliance on Interqual ISSI criteria
Use of admission criteria or guidelines for many conditions
Pneumonia DVT CHF PID asthma
Alternatives to inpatient stay
One Day ReadmissionsPines JM et al Post discharge adverse events for 1-day hospital admissions in older adults admitted from the emergency department Ann Emerge Med 201056253-257
Examined ED readmissions with 1 day stays
121 of all patients
CHF COPD prior hx of CHF
841 patients of 1207 admitted
12 died within 30 days
3 had definitive FU 4 missed FU appointment
Questions
Is it due to premature hospital discharge
Was a one day admission necessary
Alternatives to Inpatient Admission
Observational care
Psychiatric Patients
Acute psychiatric stabilization
Crisis respite
Day hospitals
Living room care
Hospital at Home care
Discharge to Hospital at Home Leff B Defining and disseminating the hospital-at-home model CMAJ 2009 Jan 20180(2)156-7 doi 101503cmaj081891
Have EPs PCPs and home care staff identify patients to benefit from receiving hospital-level care at home
Physician visits at least once daily and 24-hour coverage
Nursing visits once or twice daily
Telehealth nurses providing remote support
Remote monitoring of key health indicators
$1500 less than a comparable inpatient stay
For Admitted Patients Acute Carersquos Role
Start patient in care management
Case management
Social work
Discharge planning
Pharmacy
Occupational and speech therapy
Nutritional service
Identify patients that are at risk for readmission
ED Discharge
Set up follow up appointmentsSharma G et al Outpatient follow-up visits and 30 day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease Arch Intern Med 20101701664-1670
62746 COPD patients 669 had PCP follow up
Patients who follow up visit reduced the risk of an ED visit and readmission
Begin case management Gil M et al Impact of a combined pharmacist and social
worker program to reduce hospital readmission J Mang Care Pharm 201319558-583
Involve social work and pharmacy
Set up home health services
Med reconciliation and FU phone calls
Communicate with PCP Pang PS et al Patients with acute heart failure in the
emergency department do they all need to be admitted J Cardiac Fail 201218900-903
Hand off to primary care
For Discharged PatientsAcute Carersquos Role
Clear detailed discharge plans tailored to patient family clinicians case managers and payers Teach self-care
Improved instructions and instruction process
Patient read back
Encourage self-management
Telehealth technology to monitor at home
Physiciannursesocial worker phone calls
Assign a patient navigator
Value of Patient NavigatorBalaban R et alA randomized controlled trial of a patient navigator intervention in reduce hospital readmissions in a safety new healthcare system CMAR 20133157-158
Role of patient navigator
Support and guidance throughout healthcare continuum
Coordinates appointments
Maintains communications
Arranges interpreter services
Arranges patient transportation
Facilitates linkages to follow up
Study of patient navigators 423 patient navigator and 513 in control
121 were readmitted in patient navigator group and 136 in control group
Super UsersEduardo J LaCalle MD MPH Elaine J Rabin MD and Nicholas G Genes MD PHD HIGH-FREQUENCY USERS OF EMERGENCY DEPARTMENT CARE J Emer Med44 No 6 pp 1167ndash1173 2013
Demographic and utilization characteristics of patients who visit the ED 20 or more times per year
Retrospectively studied patients who visited a large urban ED over a
High-frequency ED users contributing 11 of all visits
More likely to be 30ndash59 years of age (52) insured (81) and have at least one significant psychosocial cofactor (65)
Admission rate was 15
High-frequency users are patients with significant psychiatric and social comorbidities
Effective Interventions for Frequent ED UsersAlthaus E at al Effectiveness of interventions targeting frequent users of emergency department a systematic review Ann Emerg Med 201158 41-52
Reviewed 11 studies
Case management most often studied 7
Demonstrated
Reduced ED use
Reduced cost
Reduced homelessness
Case ManagementRyan P McCormack MD Lily F Hoffman MS Stephen P Wall MD MSc MAEd and Lewis R Goldfrank MD Resource-Limited Collaborative Pilot Intervention for Chronically Homeless Alcohol-Dependent Frequent Emergency Department Users Am J Public Health 2013103S221ndashS224
Case management and homeless outreach to chronically homeless alcohol-dependent frequent emergency department (ED)
The differences between intervention and prospective patients and retrospective controls were ndash121 for ED visits and ndash85 for inpatient days
Eighteen participants accepted shelter no controls were housed
Through intervention ED use decreased and housing was achieved
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Reliance on Interqual ISSI criteria
Use of admission criteria or guidelines for many conditions
Pneumonia DVT CHF PID asthma
Alternatives to inpatient stay
One Day ReadmissionsPines JM et al Post discharge adverse events for 1-day hospital admissions in older adults admitted from the emergency department Ann Emerge Med 201056253-257
Examined ED readmissions with 1 day stays
121 of all patients
CHF COPD prior hx of CHF
841 patients of 1207 admitted
12 died within 30 days
3 had definitive FU 4 missed FU appointment
Questions
Is it due to premature hospital discharge
Was a one day admission necessary
Alternatives to Inpatient Admission
Observational care
Psychiatric Patients
Acute psychiatric stabilization
Crisis respite
Day hospitals
Living room care
Hospital at Home care
Discharge to Hospital at Home Leff B Defining and disseminating the hospital-at-home model CMAJ 2009 Jan 20180(2)156-7 doi 101503cmaj081891
Have EPs PCPs and home care staff identify patients to benefit from receiving hospital-level care at home
Physician visits at least once daily and 24-hour coverage
Nursing visits once or twice daily
Telehealth nurses providing remote support
Remote monitoring of key health indicators
$1500 less than a comparable inpatient stay
For Admitted Patients Acute Carersquos Role
Start patient in care management
Case management
Social work
Discharge planning
Pharmacy
Occupational and speech therapy
Nutritional service
Identify patients that are at risk for readmission
ED Discharge
Set up follow up appointmentsSharma G et al Outpatient follow-up visits and 30 day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease Arch Intern Med 20101701664-1670
62746 COPD patients 669 had PCP follow up
Patients who follow up visit reduced the risk of an ED visit and readmission
Begin case management Gil M et al Impact of a combined pharmacist and social
worker program to reduce hospital readmission J Mang Care Pharm 201319558-583
Involve social work and pharmacy
Set up home health services
Med reconciliation and FU phone calls
Communicate with PCP Pang PS et al Patients with acute heart failure in the
emergency department do they all need to be admitted J Cardiac Fail 201218900-903
Hand off to primary care
For Discharged PatientsAcute Carersquos Role
Clear detailed discharge plans tailored to patient family clinicians case managers and payers Teach self-care
Improved instructions and instruction process
Patient read back
Encourage self-management
Telehealth technology to monitor at home
Physiciannursesocial worker phone calls
Assign a patient navigator
Value of Patient NavigatorBalaban R et alA randomized controlled trial of a patient navigator intervention in reduce hospital readmissions in a safety new healthcare system CMAR 20133157-158
Role of patient navigator
Support and guidance throughout healthcare continuum
Coordinates appointments
Maintains communications
Arranges interpreter services
Arranges patient transportation
Facilitates linkages to follow up
Study of patient navigators 423 patient navigator and 513 in control
121 were readmitted in patient navigator group and 136 in control group
Super UsersEduardo J LaCalle MD MPH Elaine J Rabin MD and Nicholas G Genes MD PHD HIGH-FREQUENCY USERS OF EMERGENCY DEPARTMENT CARE J Emer Med44 No 6 pp 1167ndash1173 2013
Demographic and utilization characteristics of patients who visit the ED 20 or more times per year
Retrospectively studied patients who visited a large urban ED over a
High-frequency ED users contributing 11 of all visits
More likely to be 30ndash59 years of age (52) insured (81) and have at least one significant psychosocial cofactor (65)
Admission rate was 15
High-frequency users are patients with significant psychiatric and social comorbidities
Effective Interventions for Frequent ED UsersAlthaus E at al Effectiveness of interventions targeting frequent users of emergency department a systematic review Ann Emerg Med 201158 41-52
Reviewed 11 studies
Case management most often studied 7
Demonstrated
Reduced ED use
Reduced cost
Reduced homelessness
Case ManagementRyan P McCormack MD Lily F Hoffman MS Stephen P Wall MD MSc MAEd and Lewis R Goldfrank MD Resource-Limited Collaborative Pilot Intervention for Chronically Homeless Alcohol-Dependent Frequent Emergency Department Users Am J Public Health 2013103S221ndashS224
Case management and homeless outreach to chronically homeless alcohol-dependent frequent emergency department (ED)
The differences between intervention and prospective patients and retrospective controls were ndash121 for ED visits and ndash85 for inpatient days
Eighteen participants accepted shelter no controls were housed
Through intervention ED use decreased and housing was achieved
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
One Day ReadmissionsPines JM et al Post discharge adverse events for 1-day hospital admissions in older adults admitted from the emergency department Ann Emerge Med 201056253-257
Examined ED readmissions with 1 day stays
121 of all patients
CHF COPD prior hx of CHF
841 patients of 1207 admitted
12 died within 30 days
3 had definitive FU 4 missed FU appointment
Questions
Is it due to premature hospital discharge
Was a one day admission necessary
Alternatives to Inpatient Admission
Observational care
Psychiatric Patients
Acute psychiatric stabilization
Crisis respite
Day hospitals
Living room care
Hospital at Home care
Discharge to Hospital at Home Leff B Defining and disseminating the hospital-at-home model CMAJ 2009 Jan 20180(2)156-7 doi 101503cmaj081891
Have EPs PCPs and home care staff identify patients to benefit from receiving hospital-level care at home
Physician visits at least once daily and 24-hour coverage
Nursing visits once or twice daily
Telehealth nurses providing remote support
Remote monitoring of key health indicators
$1500 less than a comparable inpatient stay
For Admitted Patients Acute Carersquos Role
Start patient in care management
Case management
Social work
Discharge planning
Pharmacy
Occupational and speech therapy
Nutritional service
Identify patients that are at risk for readmission
ED Discharge
Set up follow up appointmentsSharma G et al Outpatient follow-up visits and 30 day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease Arch Intern Med 20101701664-1670
62746 COPD patients 669 had PCP follow up
Patients who follow up visit reduced the risk of an ED visit and readmission
Begin case management Gil M et al Impact of a combined pharmacist and social
worker program to reduce hospital readmission J Mang Care Pharm 201319558-583
Involve social work and pharmacy
Set up home health services
Med reconciliation and FU phone calls
Communicate with PCP Pang PS et al Patients with acute heart failure in the
emergency department do they all need to be admitted J Cardiac Fail 201218900-903
Hand off to primary care
For Discharged PatientsAcute Carersquos Role
Clear detailed discharge plans tailored to patient family clinicians case managers and payers Teach self-care
Improved instructions and instruction process
Patient read back
Encourage self-management
Telehealth technology to monitor at home
Physiciannursesocial worker phone calls
Assign a patient navigator
Value of Patient NavigatorBalaban R et alA randomized controlled trial of a patient navigator intervention in reduce hospital readmissions in a safety new healthcare system CMAR 20133157-158
Role of patient navigator
Support and guidance throughout healthcare continuum
Coordinates appointments
Maintains communications
Arranges interpreter services
Arranges patient transportation
Facilitates linkages to follow up
Study of patient navigators 423 patient navigator and 513 in control
121 were readmitted in patient navigator group and 136 in control group
Super UsersEduardo J LaCalle MD MPH Elaine J Rabin MD and Nicholas G Genes MD PHD HIGH-FREQUENCY USERS OF EMERGENCY DEPARTMENT CARE J Emer Med44 No 6 pp 1167ndash1173 2013
Demographic and utilization characteristics of patients who visit the ED 20 or more times per year
Retrospectively studied patients who visited a large urban ED over a
High-frequency ED users contributing 11 of all visits
More likely to be 30ndash59 years of age (52) insured (81) and have at least one significant psychosocial cofactor (65)
Admission rate was 15
High-frequency users are patients with significant psychiatric and social comorbidities
Effective Interventions for Frequent ED UsersAlthaus E at al Effectiveness of interventions targeting frequent users of emergency department a systematic review Ann Emerg Med 201158 41-52
Reviewed 11 studies
Case management most often studied 7
Demonstrated
Reduced ED use
Reduced cost
Reduced homelessness
Case ManagementRyan P McCormack MD Lily F Hoffman MS Stephen P Wall MD MSc MAEd and Lewis R Goldfrank MD Resource-Limited Collaborative Pilot Intervention for Chronically Homeless Alcohol-Dependent Frequent Emergency Department Users Am J Public Health 2013103S221ndashS224
Case management and homeless outreach to chronically homeless alcohol-dependent frequent emergency department (ED)
The differences between intervention and prospective patients and retrospective controls were ndash121 for ED visits and ndash85 for inpatient days
Eighteen participants accepted shelter no controls were housed
Through intervention ED use decreased and housing was achieved
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Alternatives to Inpatient Admission
Observational care
Psychiatric Patients
Acute psychiatric stabilization
Crisis respite
Day hospitals
Living room care
Hospital at Home care
Discharge to Hospital at Home Leff B Defining and disseminating the hospital-at-home model CMAJ 2009 Jan 20180(2)156-7 doi 101503cmaj081891
Have EPs PCPs and home care staff identify patients to benefit from receiving hospital-level care at home
Physician visits at least once daily and 24-hour coverage
Nursing visits once or twice daily
Telehealth nurses providing remote support
Remote monitoring of key health indicators
$1500 less than a comparable inpatient stay
For Admitted Patients Acute Carersquos Role
Start patient in care management
Case management
Social work
Discharge planning
Pharmacy
Occupational and speech therapy
Nutritional service
Identify patients that are at risk for readmission
ED Discharge
Set up follow up appointmentsSharma G et al Outpatient follow-up visits and 30 day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease Arch Intern Med 20101701664-1670
62746 COPD patients 669 had PCP follow up
Patients who follow up visit reduced the risk of an ED visit and readmission
Begin case management Gil M et al Impact of a combined pharmacist and social
worker program to reduce hospital readmission J Mang Care Pharm 201319558-583
Involve social work and pharmacy
Set up home health services
Med reconciliation and FU phone calls
Communicate with PCP Pang PS et al Patients with acute heart failure in the
emergency department do they all need to be admitted J Cardiac Fail 201218900-903
Hand off to primary care
For Discharged PatientsAcute Carersquos Role
Clear detailed discharge plans tailored to patient family clinicians case managers and payers Teach self-care
Improved instructions and instruction process
Patient read back
Encourage self-management
Telehealth technology to monitor at home
Physiciannursesocial worker phone calls
Assign a patient navigator
Value of Patient NavigatorBalaban R et alA randomized controlled trial of a patient navigator intervention in reduce hospital readmissions in a safety new healthcare system CMAR 20133157-158
Role of patient navigator
Support and guidance throughout healthcare continuum
Coordinates appointments
Maintains communications
Arranges interpreter services
Arranges patient transportation
Facilitates linkages to follow up
Study of patient navigators 423 patient navigator and 513 in control
121 were readmitted in patient navigator group and 136 in control group
Super UsersEduardo J LaCalle MD MPH Elaine J Rabin MD and Nicholas G Genes MD PHD HIGH-FREQUENCY USERS OF EMERGENCY DEPARTMENT CARE J Emer Med44 No 6 pp 1167ndash1173 2013
Demographic and utilization characteristics of patients who visit the ED 20 or more times per year
Retrospectively studied patients who visited a large urban ED over a
High-frequency ED users contributing 11 of all visits
More likely to be 30ndash59 years of age (52) insured (81) and have at least one significant psychosocial cofactor (65)
Admission rate was 15
High-frequency users are patients with significant psychiatric and social comorbidities
Effective Interventions for Frequent ED UsersAlthaus E at al Effectiveness of interventions targeting frequent users of emergency department a systematic review Ann Emerg Med 201158 41-52
Reviewed 11 studies
Case management most often studied 7
Demonstrated
Reduced ED use
Reduced cost
Reduced homelessness
Case ManagementRyan P McCormack MD Lily F Hoffman MS Stephen P Wall MD MSc MAEd and Lewis R Goldfrank MD Resource-Limited Collaborative Pilot Intervention for Chronically Homeless Alcohol-Dependent Frequent Emergency Department Users Am J Public Health 2013103S221ndashS224
Case management and homeless outreach to chronically homeless alcohol-dependent frequent emergency department (ED)
The differences between intervention and prospective patients and retrospective controls were ndash121 for ED visits and ndash85 for inpatient days
Eighteen participants accepted shelter no controls were housed
Through intervention ED use decreased and housing was achieved
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Discharge to Hospital at Home Leff B Defining and disseminating the hospital-at-home model CMAJ 2009 Jan 20180(2)156-7 doi 101503cmaj081891
Have EPs PCPs and home care staff identify patients to benefit from receiving hospital-level care at home
Physician visits at least once daily and 24-hour coverage
Nursing visits once or twice daily
Telehealth nurses providing remote support
Remote monitoring of key health indicators
$1500 less than a comparable inpatient stay
For Admitted Patients Acute Carersquos Role
Start patient in care management
Case management
Social work
Discharge planning
Pharmacy
Occupational and speech therapy
Nutritional service
Identify patients that are at risk for readmission
ED Discharge
Set up follow up appointmentsSharma G et al Outpatient follow-up visits and 30 day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease Arch Intern Med 20101701664-1670
62746 COPD patients 669 had PCP follow up
Patients who follow up visit reduced the risk of an ED visit and readmission
Begin case management Gil M et al Impact of a combined pharmacist and social
worker program to reduce hospital readmission J Mang Care Pharm 201319558-583
Involve social work and pharmacy
Set up home health services
Med reconciliation and FU phone calls
Communicate with PCP Pang PS et al Patients with acute heart failure in the
emergency department do they all need to be admitted J Cardiac Fail 201218900-903
Hand off to primary care
For Discharged PatientsAcute Carersquos Role
Clear detailed discharge plans tailored to patient family clinicians case managers and payers Teach self-care
Improved instructions and instruction process
Patient read back
Encourage self-management
Telehealth technology to monitor at home
Physiciannursesocial worker phone calls
Assign a patient navigator
Value of Patient NavigatorBalaban R et alA randomized controlled trial of a patient navigator intervention in reduce hospital readmissions in a safety new healthcare system CMAR 20133157-158
Role of patient navigator
Support and guidance throughout healthcare continuum
Coordinates appointments
Maintains communications
Arranges interpreter services
Arranges patient transportation
Facilitates linkages to follow up
Study of patient navigators 423 patient navigator and 513 in control
121 were readmitted in patient navigator group and 136 in control group
Super UsersEduardo J LaCalle MD MPH Elaine J Rabin MD and Nicholas G Genes MD PHD HIGH-FREQUENCY USERS OF EMERGENCY DEPARTMENT CARE J Emer Med44 No 6 pp 1167ndash1173 2013
Demographic and utilization characteristics of patients who visit the ED 20 or more times per year
Retrospectively studied patients who visited a large urban ED over a
High-frequency ED users contributing 11 of all visits
More likely to be 30ndash59 years of age (52) insured (81) and have at least one significant psychosocial cofactor (65)
Admission rate was 15
High-frequency users are patients with significant psychiatric and social comorbidities
Effective Interventions for Frequent ED UsersAlthaus E at al Effectiveness of interventions targeting frequent users of emergency department a systematic review Ann Emerg Med 201158 41-52
Reviewed 11 studies
Case management most often studied 7
Demonstrated
Reduced ED use
Reduced cost
Reduced homelessness
Case ManagementRyan P McCormack MD Lily F Hoffman MS Stephen P Wall MD MSc MAEd and Lewis R Goldfrank MD Resource-Limited Collaborative Pilot Intervention for Chronically Homeless Alcohol-Dependent Frequent Emergency Department Users Am J Public Health 2013103S221ndashS224
Case management and homeless outreach to chronically homeless alcohol-dependent frequent emergency department (ED)
The differences between intervention and prospective patients and retrospective controls were ndash121 for ED visits and ndash85 for inpatient days
Eighteen participants accepted shelter no controls were housed
Through intervention ED use decreased and housing was achieved
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
For Admitted Patients Acute Carersquos Role
Start patient in care management
Case management
Social work
Discharge planning
Pharmacy
Occupational and speech therapy
Nutritional service
Identify patients that are at risk for readmission
ED Discharge
Set up follow up appointmentsSharma G et al Outpatient follow-up visits and 30 day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease Arch Intern Med 20101701664-1670
62746 COPD patients 669 had PCP follow up
Patients who follow up visit reduced the risk of an ED visit and readmission
Begin case management Gil M et al Impact of a combined pharmacist and social
worker program to reduce hospital readmission J Mang Care Pharm 201319558-583
Involve social work and pharmacy
Set up home health services
Med reconciliation and FU phone calls
Communicate with PCP Pang PS et al Patients with acute heart failure in the
emergency department do they all need to be admitted J Cardiac Fail 201218900-903
Hand off to primary care
For Discharged PatientsAcute Carersquos Role
Clear detailed discharge plans tailored to patient family clinicians case managers and payers Teach self-care
Improved instructions and instruction process
Patient read back
Encourage self-management
Telehealth technology to monitor at home
Physiciannursesocial worker phone calls
Assign a patient navigator
Value of Patient NavigatorBalaban R et alA randomized controlled trial of a patient navigator intervention in reduce hospital readmissions in a safety new healthcare system CMAR 20133157-158
Role of patient navigator
Support and guidance throughout healthcare continuum
Coordinates appointments
Maintains communications
Arranges interpreter services
Arranges patient transportation
Facilitates linkages to follow up
Study of patient navigators 423 patient navigator and 513 in control
121 were readmitted in patient navigator group and 136 in control group
Super UsersEduardo J LaCalle MD MPH Elaine J Rabin MD and Nicholas G Genes MD PHD HIGH-FREQUENCY USERS OF EMERGENCY DEPARTMENT CARE J Emer Med44 No 6 pp 1167ndash1173 2013
Demographic and utilization characteristics of patients who visit the ED 20 or more times per year
Retrospectively studied patients who visited a large urban ED over a
High-frequency ED users contributing 11 of all visits
More likely to be 30ndash59 years of age (52) insured (81) and have at least one significant psychosocial cofactor (65)
Admission rate was 15
High-frequency users are patients with significant psychiatric and social comorbidities
Effective Interventions for Frequent ED UsersAlthaus E at al Effectiveness of interventions targeting frequent users of emergency department a systematic review Ann Emerg Med 201158 41-52
Reviewed 11 studies
Case management most often studied 7
Demonstrated
Reduced ED use
Reduced cost
Reduced homelessness
Case ManagementRyan P McCormack MD Lily F Hoffman MS Stephen P Wall MD MSc MAEd and Lewis R Goldfrank MD Resource-Limited Collaborative Pilot Intervention for Chronically Homeless Alcohol-Dependent Frequent Emergency Department Users Am J Public Health 2013103S221ndashS224
Case management and homeless outreach to chronically homeless alcohol-dependent frequent emergency department (ED)
The differences between intervention and prospective patients and retrospective controls were ndash121 for ED visits and ndash85 for inpatient days
Eighteen participants accepted shelter no controls were housed
Through intervention ED use decreased and housing was achieved
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
ED Discharge
Set up follow up appointmentsSharma G et al Outpatient follow-up visits and 30 day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease Arch Intern Med 20101701664-1670
62746 COPD patients 669 had PCP follow up
Patients who follow up visit reduced the risk of an ED visit and readmission
Begin case management Gil M et al Impact of a combined pharmacist and social
worker program to reduce hospital readmission J Mang Care Pharm 201319558-583
Involve social work and pharmacy
Set up home health services
Med reconciliation and FU phone calls
Communicate with PCP Pang PS et al Patients with acute heart failure in the
emergency department do they all need to be admitted J Cardiac Fail 201218900-903
Hand off to primary care
For Discharged PatientsAcute Carersquos Role
Clear detailed discharge plans tailored to patient family clinicians case managers and payers Teach self-care
Improved instructions and instruction process
Patient read back
Encourage self-management
Telehealth technology to monitor at home
Physiciannursesocial worker phone calls
Assign a patient navigator
Value of Patient NavigatorBalaban R et alA randomized controlled trial of a patient navigator intervention in reduce hospital readmissions in a safety new healthcare system CMAR 20133157-158
Role of patient navigator
Support and guidance throughout healthcare continuum
Coordinates appointments
Maintains communications
Arranges interpreter services
Arranges patient transportation
Facilitates linkages to follow up
Study of patient navigators 423 patient navigator and 513 in control
121 were readmitted in patient navigator group and 136 in control group
Super UsersEduardo J LaCalle MD MPH Elaine J Rabin MD and Nicholas G Genes MD PHD HIGH-FREQUENCY USERS OF EMERGENCY DEPARTMENT CARE J Emer Med44 No 6 pp 1167ndash1173 2013
Demographic and utilization characteristics of patients who visit the ED 20 or more times per year
Retrospectively studied patients who visited a large urban ED over a
High-frequency ED users contributing 11 of all visits
More likely to be 30ndash59 years of age (52) insured (81) and have at least one significant psychosocial cofactor (65)
Admission rate was 15
High-frequency users are patients with significant psychiatric and social comorbidities
Effective Interventions for Frequent ED UsersAlthaus E at al Effectiveness of interventions targeting frequent users of emergency department a systematic review Ann Emerg Med 201158 41-52
Reviewed 11 studies
Case management most often studied 7
Demonstrated
Reduced ED use
Reduced cost
Reduced homelessness
Case ManagementRyan P McCormack MD Lily F Hoffman MS Stephen P Wall MD MSc MAEd and Lewis R Goldfrank MD Resource-Limited Collaborative Pilot Intervention for Chronically Homeless Alcohol-Dependent Frequent Emergency Department Users Am J Public Health 2013103S221ndashS224
Case management and homeless outreach to chronically homeless alcohol-dependent frequent emergency department (ED)
The differences between intervention and prospective patients and retrospective controls were ndash121 for ED visits and ndash85 for inpatient days
Eighteen participants accepted shelter no controls were housed
Through intervention ED use decreased and housing was achieved
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
For Discharged PatientsAcute Carersquos Role
Clear detailed discharge plans tailored to patient family clinicians case managers and payers Teach self-care
Improved instructions and instruction process
Patient read back
Encourage self-management
Telehealth technology to monitor at home
Physiciannursesocial worker phone calls
Assign a patient navigator
Value of Patient NavigatorBalaban R et alA randomized controlled trial of a patient navigator intervention in reduce hospital readmissions in a safety new healthcare system CMAR 20133157-158
Role of patient navigator
Support and guidance throughout healthcare continuum
Coordinates appointments
Maintains communications
Arranges interpreter services
Arranges patient transportation
Facilitates linkages to follow up
Study of patient navigators 423 patient navigator and 513 in control
121 were readmitted in patient navigator group and 136 in control group
Super UsersEduardo J LaCalle MD MPH Elaine J Rabin MD and Nicholas G Genes MD PHD HIGH-FREQUENCY USERS OF EMERGENCY DEPARTMENT CARE J Emer Med44 No 6 pp 1167ndash1173 2013
Demographic and utilization characteristics of patients who visit the ED 20 or more times per year
Retrospectively studied patients who visited a large urban ED over a
High-frequency ED users contributing 11 of all visits
More likely to be 30ndash59 years of age (52) insured (81) and have at least one significant psychosocial cofactor (65)
Admission rate was 15
High-frequency users are patients with significant psychiatric and social comorbidities
Effective Interventions for Frequent ED UsersAlthaus E at al Effectiveness of interventions targeting frequent users of emergency department a systematic review Ann Emerg Med 201158 41-52
Reviewed 11 studies
Case management most often studied 7
Demonstrated
Reduced ED use
Reduced cost
Reduced homelessness
Case ManagementRyan P McCormack MD Lily F Hoffman MS Stephen P Wall MD MSc MAEd and Lewis R Goldfrank MD Resource-Limited Collaborative Pilot Intervention for Chronically Homeless Alcohol-Dependent Frequent Emergency Department Users Am J Public Health 2013103S221ndashS224
Case management and homeless outreach to chronically homeless alcohol-dependent frequent emergency department (ED)
The differences between intervention and prospective patients and retrospective controls were ndash121 for ED visits and ndash85 for inpatient days
Eighteen participants accepted shelter no controls were housed
Through intervention ED use decreased and housing was achieved
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Value of Patient NavigatorBalaban R et alA randomized controlled trial of a patient navigator intervention in reduce hospital readmissions in a safety new healthcare system CMAR 20133157-158
Role of patient navigator
Support and guidance throughout healthcare continuum
Coordinates appointments
Maintains communications
Arranges interpreter services
Arranges patient transportation
Facilitates linkages to follow up
Study of patient navigators 423 patient navigator and 513 in control
121 were readmitted in patient navigator group and 136 in control group
Super UsersEduardo J LaCalle MD MPH Elaine J Rabin MD and Nicholas G Genes MD PHD HIGH-FREQUENCY USERS OF EMERGENCY DEPARTMENT CARE J Emer Med44 No 6 pp 1167ndash1173 2013
Demographic and utilization characteristics of patients who visit the ED 20 or more times per year
Retrospectively studied patients who visited a large urban ED over a
High-frequency ED users contributing 11 of all visits
More likely to be 30ndash59 years of age (52) insured (81) and have at least one significant psychosocial cofactor (65)
Admission rate was 15
High-frequency users are patients with significant psychiatric and social comorbidities
Effective Interventions for Frequent ED UsersAlthaus E at al Effectiveness of interventions targeting frequent users of emergency department a systematic review Ann Emerg Med 201158 41-52
Reviewed 11 studies
Case management most often studied 7
Demonstrated
Reduced ED use
Reduced cost
Reduced homelessness
Case ManagementRyan P McCormack MD Lily F Hoffman MS Stephen P Wall MD MSc MAEd and Lewis R Goldfrank MD Resource-Limited Collaborative Pilot Intervention for Chronically Homeless Alcohol-Dependent Frequent Emergency Department Users Am J Public Health 2013103S221ndashS224
Case management and homeless outreach to chronically homeless alcohol-dependent frequent emergency department (ED)
The differences between intervention and prospective patients and retrospective controls were ndash121 for ED visits and ndash85 for inpatient days
Eighteen participants accepted shelter no controls were housed
Through intervention ED use decreased and housing was achieved
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Super UsersEduardo J LaCalle MD MPH Elaine J Rabin MD and Nicholas G Genes MD PHD HIGH-FREQUENCY USERS OF EMERGENCY DEPARTMENT CARE J Emer Med44 No 6 pp 1167ndash1173 2013
Demographic and utilization characteristics of patients who visit the ED 20 or more times per year
Retrospectively studied patients who visited a large urban ED over a
High-frequency ED users contributing 11 of all visits
More likely to be 30ndash59 years of age (52) insured (81) and have at least one significant psychosocial cofactor (65)
Admission rate was 15
High-frequency users are patients with significant psychiatric and social comorbidities
Effective Interventions for Frequent ED UsersAlthaus E at al Effectiveness of interventions targeting frequent users of emergency department a systematic review Ann Emerg Med 201158 41-52
Reviewed 11 studies
Case management most often studied 7
Demonstrated
Reduced ED use
Reduced cost
Reduced homelessness
Case ManagementRyan P McCormack MD Lily F Hoffman MS Stephen P Wall MD MSc MAEd and Lewis R Goldfrank MD Resource-Limited Collaborative Pilot Intervention for Chronically Homeless Alcohol-Dependent Frequent Emergency Department Users Am J Public Health 2013103S221ndashS224
Case management and homeless outreach to chronically homeless alcohol-dependent frequent emergency department (ED)
The differences between intervention and prospective patients and retrospective controls were ndash121 for ED visits and ndash85 for inpatient days
Eighteen participants accepted shelter no controls were housed
Through intervention ED use decreased and housing was achieved
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Effective Interventions for Frequent ED UsersAlthaus E at al Effectiveness of interventions targeting frequent users of emergency department a systematic review Ann Emerg Med 201158 41-52
Reviewed 11 studies
Case management most often studied 7
Demonstrated
Reduced ED use
Reduced cost
Reduced homelessness
Case ManagementRyan P McCormack MD Lily F Hoffman MS Stephen P Wall MD MSc MAEd and Lewis R Goldfrank MD Resource-Limited Collaborative Pilot Intervention for Chronically Homeless Alcohol-Dependent Frequent Emergency Department Users Am J Public Health 2013103S221ndashS224
Case management and homeless outreach to chronically homeless alcohol-dependent frequent emergency department (ED)
The differences between intervention and prospective patients and retrospective controls were ndash121 for ED visits and ndash85 for inpatient days
Eighteen participants accepted shelter no controls were housed
Through intervention ED use decreased and housing was achieved
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Case ManagementRyan P McCormack MD Lily F Hoffman MS Stephen P Wall MD MSc MAEd and Lewis R Goldfrank MD Resource-Limited Collaborative Pilot Intervention for Chronically Homeless Alcohol-Dependent Frequent Emergency Department Users Am J Public Health 2013103S221ndashS224
Case management and homeless outreach to chronically homeless alcohol-dependent frequent emergency department (ED)
The differences between intervention and prospective patients and retrospective controls were ndash121 for ED visits and ndash85 for inpatient days
Eighteen participants accepted shelter no controls were housed
Through intervention ED use decreased and housing was achieved
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Case Management in the EDAdvocate Illinois Masonic
The Medically Integrated Crisis Community Support (MICCS) Team was created in the Spring of 2014 It combines the typical range of interventions to stabilize a crisis with new interventions and methods It mirrors the intensity of ED care but seeks to move that level of care into community settings and transition brief high-cost interventions into longer engagement-oriented support episodes
Patient
Centered
Care
Psychiatrist
Social Worker X2 LCSWrsquos
Social Worker Trainee
Nurse
Security
Recovery Support
Specialist
Chaplain
Mental Health
Counselor
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
HomelessAm J Public Health 200292778ndash784
Interviews were conducted with 2578 homeless and marginally housed persons
404 of respondents had 1 or more emergency department encounters in the previous year
79 exhibited high rates of use (more than 3 visits)
Factors associated with high use rates
Less stable housing
Victimization amp arrests
Physical and mental illness
Substance abuse
Targeted underlying risk factors among those exhibiting high rates of use
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
HomelessMccormick RP Resource-limited collaborative pilot for chronically homeless alcohol dependent frequent emergency department users AM J Pub Health 2013103 S221-4
Case management of chronically homeless alcoholic persons
Compared intervention to controls
Reduced ED visits by 121 ED visits for 6 months
Reduced 85 inpatient days
18 participants intervention group accepted shelter
None in control group accepted housing
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Patient Types-AlcoholicSobering Center-Definition
Facilities that provide a safe supportive environment for mostly uninsured homeless publically intoxicated persons to become sober
Alternative holding facility for patient who are intoxicated
Alternative to jail holding cell or ED
May go directly to sobering center by police ambulance or center sponsored transport
May go to an ED first
May receive counseling and referrals
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
24
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Before Patient Arrives Identification of Seniors at Risk ToolsGraf CE et al Identification of older patients at risk of unplanned readmission after discharge form the emergency department Swiss Med Weekly 2012142w13327
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST
Modest prediction of unplanned readmission after ED visit in patients over 75 years old
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Triage Risk Screening Tool
1 History of cognitive impairment (poor recall or not oriented)2 Difficulty walking transferring or recent falls3 Five or more medications4 ED use in previous 30 days or hospitalization in previous 90 days5 Lives alone andor no available caregiver6 ED staff professional recommendationsNutrition weight loss IncontinenceFailure to cope Medication issuesSensory deficits Depression low mood
If 2 or more factors identified high risk
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Identification of Senior at RiskRosted E The Identification of Seniors at Risk screening toolis useful for predicting acute readmissions Dan Med J 201461(5)A4828
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS1 Have you needed help on a regular basis (from home carehome nurse relatives or others) prior to the illness that causedthe hospitalization
2 Have you needed more help (ie for personal care) than usual tobe able to take care of yourself after the illness arose which causedthe hospitalization
3 Have you been hospitalized for one or more days during the last6 months not including visits to the Casualty Ward
4 Is your vision usually good
5 Do you usually have serious memory problems
6 Do you use more than 3 different types of medicine a day
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Psychiatric Patient Admission Criteria Does the Patient Need to Be Admitted
Not always an easy decision
Use of admission criteria or guidelines for many conditions Risk to self Risk to others Unable to care for self
Improved assessment for admission Telepsychiatry
Diversion programs
Suicide risk assessment
Alternatives to inpatient stay
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Patient Subsets ndash Psychiatric PatientsCOMPLIANCE OF MEDICATIONS BY PATIENTS
PRESENTING TO THE EDS Yen1 L Downey2 L Zun3 and T Burke4
There were a total of 214 participants in the study
106 medical and 108 were psychiatric
Prescribed an average of between 2 to 6 medsday
One significant difference between the two groups
Psychiatric pts were more likely to get admitted (50) than medical pts (31)
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Crisis Triage Rating ScaleBengelsdorf H et al A crisis triage rating scale brief dispositional assessment of patients at risk for hospitalization J Nerv Mental Disease 1984172424-430
Scores three categories 1-5
A Dangerousness
B Support system
C Ability to cooperative
Scoring
9 or more ndash outpatientcrisis intervention
8 or less - admit
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Admission CriteriaLyons JS et l Predicting psychiatric emergency admissions and hospital outcome Ed Care 19973579-800
Decision support tool
Criteria
Suicide potential
Danger to others
Severity of symptoms
Predicted 73 of the admissions
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Mobile Crisis Units and Telepsychiatry
Mobile Crisis Units Jugo M Smout M Bannister J A comparison in hospitalization rates between a community based mobile emergency
service and a hospital-based emergency service Aust N Z Psychiatry 200136504-508
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
TelepsychiatryShre JH Hilty DM Yellowlees P Emergency management guidelines for telepsychiatry Gen Hosp Psych 200729199-206
High provider and patient satisfaction
Wide variety of diagnosis age and complaints
Consultations diagnostic assessment medication management family and patient psychotherapy
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Determination of Suicide Risk Myths
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Maybe not
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
OutpatientCan the Suicidal Patient Go HomeKennedy SP Emergency department management of suicidal adolescents Ann Emerg Med 200443452-480
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship
Adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged
Agreement to plan and recommendations
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Observational Carebull Psychosis
bull Suicidal
bull Depressed
bull Anxiety
bull Alcohol and drug intoxicationwithdrawal
bull Social situation
Appropriate use of OBS units for
psychiatric patients
bull Provides adequate stability and containment
bull Availability of consultation liaison service
Requirements
35
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Crisis Stabilization UnitsBreslow RE Klinger BI Erickson BJ Crisis hospitalization on a psychiatric emergency service Gen Hosp Psych 198315307-315
Functions Allows time for diagnostic clarity Develop alternatives to admission Respite function Denies dependency needs
Patient types Schizophrenics Personality disorder Sucidality Substance use disorders
41 of total patients seen May reduce admission by 70
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Long Acting Injectable Antipsychotics
Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia
Haloperidol and fluphenazine
Paliperidone Risperdal Olanzapine
The use of these injections in first-episode psychosis and treatment-refractory schizophrenia
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
What Can We Do Before patient arrives
Identify high risk patients
During patientrsquos stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start discharge process
After the patient is discharged
Connect pt with out patient resources
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
What Can We Do
Use admission criteria
Avoid inappropriate admissions
Admitted patients start processes
Care management DC planning pharma
Consider alternatives sites of care
Observation home hospital acute stabilization
Identify high risk patients
Connect with additional services
Discharged patients may need assistance
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Patient Types
Psych Patients Look for deflection programs such as mobile crisis
teams and law enforcement for those that do not need acute care
Some patients can go home after evaluation with or without telepsychiatry
Alcoholic and Homeless Find housing
Case Management
Elderly Identify those at highest risk
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
Contact Information
Leslie Zun MD
Mount Sinai Hospital
1501 S California
Chicago IL 60608
773-257-6957
zunlsinaiorg
