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Nothing about me without meNothing about me without me Designing Collaborative Interventions to Reduce Rapid Psychiatric Readmissions: A patient-centered approach to mental health service planning and evaluation. Adrienne Shulman, Patient Support Specialist, Mount Sinai Hospital Rosalie Steinberg, MD, MSc, Psychiatry Resident, U. of Toronto Nadiya Sunderji, MD, FRCPC, Psychiatrist, St. Michael's HospitalDisclosures/Conflict of InterestDisclosures/Conflict of Interest NoneObjectivesObjectives Understand the challenge of rapid psychiatric readmissions and factors associated with readmission causality Review evidence for collaborative, patient centered approaches that may reduce rapid psychiatric readmissions Highlight systemic challenges to implementing patient centred mental health care and research Gain insight, from a patients lived experience, into strategies that promote engagement, treatment, acceptance and, ultimately recoveryTerminologyTerminology The term patient is used interchangeably with end-user, service user, consumer/survivor, client, or co-researcher depending on study or reference being cited. Patient experience=lived experienceThe Challenge: Rapid ReadmissionsThe Challenge: Rapid Readmissions Rapid Readmissions = readmissions w/in 30 days of d/c Likely relapse of single episode vs. recurrence of new episode partially preventable Negatively impacts on QOL and Recovery live independently, sense of hope, autonomy, positive self- identity Failure of mental health system to provide cost effective, seamless, efficient and compassionate care for our patients Perpetuate health inequities, disproportionately affecting marginalized populations who experience greater barriers in navigating and accessing mental health care and other supports after discharge.Problem Solving Rapid Psychiatric Readmission at St. Josephs Health Centre, Dr. Nadiya SunderjiRisk Factors for ReadmissionRisk Factors for Readmission SES (unemployment, disability)* Dx Schizophrenia* (BAD, Concurrent, Personality Disorder) High # of previous admissions or admissions within past yr* Impairment of Self Care* Medical Comorbidity* Decreasing LOS (?Controversial LOS also cited)* Delayed or absent outpatient care* Inpatient Psychiatrist caseload (high turnover rate = discharges per bed/per year)* Involuntary admission* (controversial) Low satisfaction with inpatient treatment Medication non-adherence* RF Rapid ReadmissionCase: Hospital XCase: Hospital X Hospital X has highest psychiatric readmission rate among all Ontario Hospitals 15% of inpatients readmitted to any hospital within 30 days, 23% within 90 days Highest rate of MH&A ED visits of all TCLHIN hospitals Highest rate of police drop-offs (possible proxy for illness severity) Economic Burden (approx. $2million/yr) direct care cost Excludes indirect costs: ED visits, physician compensation, police, ambulance, medical services, readmissions to other hospitals(ICES) to solve the problem: Designing Multimodal How to solve the problem: Designing Multimodal Interventions to Address Underlying CausesInterventions to Address Underlying Causes Facilitate transitions in care (case managers, aftercare plans) Increase access to and navigation of outpatient and community- based resources Improved QOL and function after discharge from hospital (Increased self care) Focus on modifiable RFs (medication adherence) Enhance our understanding of re-admission causalityKaprow 2007, Dixon 2009, Reynolds, 2004 Forchuck, 2005Vigod S, Kurdyak P Transitional interventions to reduce early psychiatric readmissions in adults: systematic review, The British Journal of Psychiatry (2013) 202: 187-194 Discordance and Admission causality > 25% patients explain symptoms other than biologic cause Side by side comparison of service users and clinicians Patients: External Stressors acute crisis, lack of supportive housing, stigma, financial, pressure from family Clinicians: Individual Deficits non-adherence with medication Poor impulse control, non-engagement with services. Attributional differences may explain poor treatment efficacy or why interventions may be more acceptable and effective than othersMgutshini, T., (2010) Risk factors for psychiatric re-hospitalization: An exploration International Journal of Mental Health Nursing (19), 257267PatientPatient--Provider Discordance Provider Discordance A Matter of PerspectiveA Matter of PerspectivePatients' perspectives on readmission causality have Patients' perspectives on readmission causality have been overlooked: Gap in the Literature been overlooked: Gap in the Literature Critical oversight in the re-hospitalization research Medically driven studies Few Qualitative studies Attribution Theory (Emic vs Etic) Patient Perspectives on Readmission Causality and Readmission Prevention Perception that admission is unjust coercive Patients perceived needs differs from clinicians Discordance attribution errors care plan/treatment goals are narrowly focused decreased engagement adherenceSayre, J., The patient's diagnosis: Explanatory models of mental illness. (2000). Qualitative Health Research, 10(1), 71-83Priebe, (2009). Patients' views of readmissions 1 year after involuntary hospitalisation. The British Journal of Psychiatry, 194(1), 49-54. Katsakou, et. Al (2012). Psychiatric patients' views on why their involuntary hospitalisation was right or wrong: a qualitative study. Social Psychiatry and Psychiatric Epidemiology, 47(7), 1169-1179Brems, C. et. al. (2004) Consumer Perspectives on services needed to prevent psychiatric hospitalization Administration and Policy in Mental Health, 32(1)You can only design interventions if youYou can only design interventions if you understand the problem. Whatunderstand the problem. Whats missing?s missing? Lack of emphasis on patient centeredness in psychiatry one explanation for high rates of treatment non-adherence and dropout among individuals with schizophrenia Application of patient-centered care principles within the mental health system has been shown to improve the understanding of provider-intervention-patient interaction, a missing piece to designing interventions that are congruent with patients beliefs and preferences about treatment initiation, treatment adherence, and treatment maintenance.Kreyenbuhl, et. al (Jul 2009). Disengagement from mental health treatment among individuals with schizophrenia and strategies for facilitating connections to care: A review of the literature. Schizophrenia Bulletin, 35(4), 696-703. Barg, (2010). When late-life depression improves: What do older patients say about their treatment?. American Journal of Geriatric Psychiatry, 18(7), 596-605Definition of Patient and Family Centred CareDefinition of Patient and Family Centred CareAnapproachtoplanning,deliveryandevaluation ofhealthcarethatisgroundedinmutually beneficialpartnerships amongpatients,families andhealthcareproviders.InstituteforPatientandFamilyCenteredCareProvidingcarethatisrespectfulofandresponsive toindividualpatientpreferences,needs,and values,andensuringthatpatientvaluesguideall clinicaldecisions.InstituteofMedicine, CommitteeonQualityof HealthCareinAmerica.CrossingtheQualityChasm:ANewHealth Systemforthe21stCentury.PFCC is guided by four principles:PFCC is guided by four principles:Three Driving Forces in HealthcareThree Driving Forces in HealthcareSystem centred Patient/Family Focused Patient/Family Centred Patient and Family Patient and Family CentredCentred Driving ForcesDriving ForcesThe priorities and choices of patients and families in partnership with the healthcare team drive the planning, delivery and evaluation of healthcare,d.bmk&psig=AFQjCNGTSL2l1Y3HBX-CaqHnXZzlJ2d7eQ&ust=1363534300568434Patient Family Centred Care involves a new Patient Family Centred Care involves a new way of thinking and workingway of thinking and workingPFCC is a shift from the traditionalFrom: What health professionals do to and for clientsTo: What health professionals do with clientsImplementation of PFCC: WhatImplementation of PFCC: Whats Required? s Required? A Fundamental Philosophical ShiftA Fundamental Philosophical Shift Strengths Collaboration Partnership model Information sharing(+) Support Flexibility EmpowermentDeficitsControlExpert ModelKnowledge (gate-keeping)(-) SupportRigidityDependenceKnowledge is Power. Who is the Expert?Knowledge is Power. Who is the Expert?What Research shows about Outcomes of PFCCWhat Research shows about Outcomes of PFCC Improved patient and family outcomes Patients who are active participants in their care experience better outcomes than those who are not similarly engaged* Increased patient and family satisfaction Decreased healthcare costs More effective use of healthcare resources Increased professional satisfaction* Hope and optimism for the future (Shulman)*2001, Agency for Healthcare Research and Quality (AHRQ) highlighted research supporting active inclusion of patients)Increased Professional SatisfactionIncreased Professional Satisfaction Improved Inter-Professional Collaboration Process of communication and decision-making that enables the separate and shared knowledge of health care providers to synergistically influence the patient care provided (Way, Jones, Busing 2000) Improved work satisfaction/quality of work life Less burnout Less staff turnover Patient adherence to treatment plans New learning for residents and students Better team functioning and communication ? Functioning Team Patient and Family Centred Care Team Functioning? Implementing PFCCImplementing PFCC Medical College of Georgia Neuroscience CentreMedical College of Georgia Neuroscience Centre Patient Satisfaction 10th 90th percentile Length of stay 50% in Neurosurgery Staff vacancy rate 7.5% 0% (now a waiting list to work there) Medication errors by 62% Patient complaints by 67% Improved perceptions of PFCC Staff own and protect the new cultureBenefits of Consumer Involvement in Benefits of Consumer Involvement in MH Planning and Service DeliveryMH Planning and Service Delivery Improved clinical outcomes hospitalization, relapse rates and criminal involvement Reduction in patient-rated unmet social needs Promotion of recovery, self-help and fostering of hope Consumer involvement predicted improved subjective QOL and functional outcomes Treatment choice increased adherence to psychiatric treatment Challenge traditional power differentials consumer empowerment leads to better outcomes Conceptualize service users beyond illness identityConsumer Involvement Improves Quality, Practice and Consumer Involvement Improves Quality, Practice and Validity of Validity of Mental Health ResearchMental Health Research Development of congruent research priorities Recruitment and retention of study participants Selection appropriate and acceptable outcome measures Credibility of the research Individual benefits for consumers/co-researchers Skill building/empowerment: training in research methodology (demystifying research) Changing treatment endpoints based on patient preferences Improved quality of research (data acquisition, interpretation and application of findings etc.)Carey, Callander, Eisen, Fleming, Fossey, Moltu, Ochocka, Oakley, Thornicraft Words from our patientsWords from our patients I want you to see me as a human being, not as a diagnosis. I hear what you are all saying out in the hallway. Why dont you come into my room and tell me what is going on. I see you writing things down in my chart. How come I cant see it? My doctor doesnt hear me. Why do I have to wear this hospital gown? Who makes up these rules? Last time I saw Dr. X. Now its Dr. Y. Why cant I have the same doctor?. Ive already told my story 3 times. Dont you people talk to each other?Barriers to Meaningful Inclusion of Patients Barriers to Meaningful Inclusion of Patients and Familiesand Families Structural and Attitudinal Barriers: Financial and human resources Inadequate training and education (staff and patients) Lack of incentives (reward or recognition in research) Hidden curriculum Primarily Clinician Attitudes Stigma Tokenism Service Culture Culture eats strategy for lunch Not Valuing Consumer Participation as Credible Resistance to ChangeGreenall, P. (2006) The barriers to patient-driven treatment in mental health: Why patients may choose to follow their own path, Leadership in Health Services 19 (1). Hall, P. (2005) Interprofessional teamwork: Professional cultures as barriers. Journal of Interprofessional Care. 1: 199-196Role of Patient AdvisorsRole of Patient Advisors--The Lived ExperienceThe Lived Experience Implementing Advisory role in Mental Health settings First Do No Harm Avoid Tokenism Accountability with no authority undermining, detrimental Role Clarity Just having a MH diagnosis doesnt mean youre qualified Can be therapeutic, but do not use as therapy Lived Experience: How it can influence future readmissions? Discharge Planning Family Meetings Groups Other creative ways to include patients as partners Getting Started Send a team to IPFCC Bottom up and top down approachRose, D., (2003b). Having a diagnosis is a qualification for the job. British Medical Journal, 326, 1331.Drivers of SuccessDrivers of Success Engagement of Patients, Families and Communities Senior Leadership Commitment, Support and Accountability PFCC Champions Create a Workplace that Supports Adoption of PFCC Physician Leads Education and Training of Healthcare Providers and Students Integrate PFCC Concepts into Every Policy, Initiative, Program and Research ProjectSummary and Take Home Points Summary and Take Home Points Rapid psychiatric readmissions represent a failure of mental health care coordination and continuity. Patients' perspectives on readmission causality have been overlooked. Treatment decisions should be guided by service users lived experience. Patient-centered approaches can address key quality issue and improve inter-professional team functioning.Summary and Take Home PointsSummary and Take Home Points Patients' involvement in their own treatment planning decisions are highly correlated with positive mental health outcomes. Organizational culture and clinician attitudes must be supportive and empowering and avoid tokenism and re-stigmatization. Eliciting patient perceptions in MH service delivery and research can inform and transform design and evaluation of interventions that are appropriate and effective in reducing rapid psychiatric readmissions. PFCC is a Journey. PFCC is a Journey. Where do we go from here? Where do we go from here? What we call the beginning is often the end. And to make an end is to make a beginning. The end is where we start from.T.S. EliotQuestions and Comments?Questions and Comments?References1. AgencyforHealthcareResearchandQuality(AHRQ)highlightedresearchsupportingactiveinclusionofpatients,20012. Barg, treatment?. AmericanJournalofGeriatricPsychiatry,18(7),5966053. Bennetts,W.,Cross,W.,&Bloomer,M.(2011).Understandingconsumerparticipationinmentalhealth:Issuesofpowerandchange.InternationalJournalofMentalHealthNursing, 20(3),1551644. Brems,,32(1)5. Fetter,M.,Lowery,B.,PsychiatricRehospitalization oftheseverelymentallyill:patientandstaffperspectives,Nusring Research41(5),301305.6. Fossey,E.,Epstein,M.,Findlay,R.,Plant,G.,&Harvey,C.(2002).Creatingapositiveexperienceofresearchforpeoplewithpsychiatricdisabilitiesbysharingfeedback.Psychiatr Rehabil J, 25(4),369378.7. Geller,J.,(2012), PatientCentered,RecoveryOrientedPsychiatricCareandTreatmentAreNotAlwaysVoluntary,PsychiatricServices, 63(5),493495.8. Hodges,JohnQ.(2005).Inclusionofmentalhealthconsumersonresearchteams.PsychiatricServices,56(9),11581159.9. Greenall,P.(2006)Thebarrierstopatientdriventreatmentinmentalhealth:Whypatientsmaychoosetofollowtheirownpath,LeadershipinHealthServices19 (1)10. Hall,P.(2005)Interprofessional teamwork:Professionalculturesasbarriers.JournalofInterprofessional Care.1:19919611. Horsfall,Jan,Cleary,Michelle,Walter,Garry,&Malins,Gillian.(2007).Challengingconventionalpractice:placingconsumersatthecentreoftheresearchenterprise.IssuesinMental HealthNursing,28(11),12011213.12. Hutchinson,A.,&Lovell,A.(2012).Participatoryactionresearch:movingbeyondthementalhealth'serviceuser'identity.JPsychiatr Ment HealthNursing13. ICES InstituteofMedicine, CommitteeonQualityofHealthCareinAmerica.CrossingtheQualityChasm:ANewHealthSystemforthe21stCentury.15. Katsakou,Christina,Rose,Diana,Amos,Tim,Bowers,Len,McCabe,Rosemarie,Oliver,Danielle,...Priebe,Stefan.(2012).Psychiatricpatients'viewsonwhytheirinvoluntary hospitalisation wasrightorwrong:aqualitativestudy.SocialPsychiatryandPsychiatricEpidemiology,47(7),1169117916. Kaprow 2007,Dixon2009,Reynolds,2004Forchuck,200517. Kreyenbuhl, literature. SchizophreniaBulletin,35(4),696703.18. MentalHealthCommissionofCanada.(2009).Towardrecoveryandwellbeing:AframeworkforamentalhealthstrategyforCanada.19. Mgutshini,T.,(2010)Riskfactorsforpsychiatricrehospitalization:AnexplorationInternationalJournalofMentalHealthNursing (19),25726720. Moltu,C.,Stefansen,J.,Svisdahl,M.,&Veseth,M.(2012).Negotiatingthecoresearchermandate serviceusers'experiencesofdoingcollaborativeresearchonmentalhealth.Disability &Rehabilitation,34(19),16081616.21. Oakley,Karen,Malins,Gillian,Riste,Louisa,&Allan,John.(2011).Consumerparticipationinserviceevaluationandqualityimprovement:keyingredientsforasystemtodelivernational indicators.AustralasianPsychiatry,19(6),49349722. Ochocka,J.,Janzen,R.,&Nelson,G.(2002).Sharingpowerandknowledge:professionalandmentalhealthconsumer/survivorresearchers workingtogetherinaparticipatoryaction researchproject.Psychiatr Rehabil J,25(4),379387.23. Priebe,Stefan,Katsakou,Christina,Amos,Tim,Leese,Morven,Morriss,Richard,Rose,Diana,...Yeeles,Ksenija.(2009).Patients'viewsofreadmissions1yearafterinvoluntary hospitalisation.TheBritishJournalofPsychiatry,194(1),4954.24. ProblemSolvingRapidPsychiatricReadmissionatSt.JosephsHealthCentre,Dr.Nadiya Sunderji25. Roick,C.,Grtner,A.,Heider,D.,Dietrich,S.,&Angermeyer,M.C.(2006).Heavyuseofpsychiatricinpatientcarefromthe perspectiveofthepatientsaffected.InternationalJournalof SocialPsychiatry,52(5),432446.26. Rose,D.,(2003b).Havingadiagnosisisaqualificationforthe job.BritishMedicalJournal,326,1331.27. Sayre,J.,Thepatient'sdiagnosis:Explanatorymodelsofmental illness.(2000).QualitativeHealthResearch,10(1),718328. Sunkel,C.(2012).Empowermentandpartnershipinmentalhealth.Lancet,379(9812),201202.29. Thornicroft G.,RoseD.,HuxleyP.,DaleG.&Wykes T.(2002).Editorial:Whataretheresearchprioritiesofmentalhealthserviceusers?JournalofMentalHealth11(1),15.30. Vigod S,Kurdyak Transitionalinterventionstoreduceearlypsychiatricreadmissionsinadults:systematicreview,TheBritishJournalofPsychiatry(2013)202:187194 Number 1Disclosures/Conflict of InterestObjectivesTerminologyThe Challenge: Rapid ReadmissionsRisk Factors for ReadmissionCase: Hospital XHow to solve the problem: Designing Multimodal Interventions to Address Underlying CausesDiscordance and Admission causalityPatient-Provider Discordance A Matter of PerspectivePatients' perspectives on readmission causality have been overlooked: Gap in the Literature You can only design interventions if youunderstand the problem. Whats missing?Definition of Patient and Family Centred CarePFCC is guided by four principles:Three Driving Forces in HealthcarePatient and Family Centred Driving ForcesPatient Family Centred Care involves a new way of thinking and workingImplementation of PFCC: Whats Required? A Fundamental Philosophical ShiftKnowledge is Power. Who is the Expert?What Research shows about Outcomes of PFCCIncreased Professional SatisfactionImplementing PFCCMedical College of Georgia Neuroscience CentreSlide Number 23Benefits of Consumer Involvement in MH Planning and Service DeliveryConsumer Involvement Improves Quality, Practice and Validity of Mental Health ResearchWords from our patientsSlide Number 27Barriers to Meaningful Inclusion of Patients and FamiliesRole of Patient Advisors-The Lived ExperienceDrivers of SuccessSummary and Take Home Points Summary and Take Home PointsPFCC is a Journey. Where do we go from here? Questions and Comments?References


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