Psychiatric Flow

Michael Trangle, MDHealthPartners, Associate Medical Director

Behavioral Health

January 20, 2015

Psychiatric Flow

Michael Trangle, MDAssociate Medical Director

Behavioral Health

Early Data

Fall 2006

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• 3-month study which involved all Mpls/St. Paul Metro hospitals with inpatient psychiatric departments including ED units (ANW, Fairview, HCMC, North Memorial, Regions, St. Josephs, United)

• Involved leadership from DHS and all 7 metro county social services leaders (Ramsey, Anoka, Hennepin, Scott, Carver, Dakota, Washington).

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E.D. Patients

• 40-50 patients per month are admitted due to lack of access to less intensive resources– 35.3% due to lack of 24 h/d skilled Medical/Behavioral

Nursing services or Intensive Residential Treatment services– 23% due to lack of substance abuse services (detox, wet bed,

dry bed, CD program with lodging)– 10% due to lack of access to psychotropic prescriber

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Metro Inpatient Psych Hospital Data• 240-250 patients per month have

“non-acute” days in the hospital • This totals to 2,000-2,100 “non

acute” days in the hospital per month

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– 29.6% of the non-acute bed days were associated with unavailable beds at AMRTC

– 22.4% of the non-acute bed days were associated with a lack of Intensive Residential Treatment beds.

– 15% of the non-acute bed days were related to court delays– 8.5% of the non-acute bed days were attributed to lack of CD

programs with lodging, need for a Rule 25 assessment, unavailability of sober beds, and need for detoxification

– 8.3% of the non-acute bed days were due to needing 24 hr/day skilled Medical/Behavioral Nursing Services – a combination of open and locked environments

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Anoka Metro Treatment Center (AMTRC) data shows• 88 patients/month have “non-acute”days • Total “non acute” days average 1,718 bed

days/months– About 51% are due to lack of Corporate Foster Care / 24

h/d skilled Behavioral/Medical Services– About 21% are due to lack of 24 h/d IRTS for complex

behavioral Needs (difficult MI/CD issues)– About 16% due to lack of housing with services availability– About 6.2% are due to lack of complex Medical/Behavioral

services

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Conclusions• Approximately 550 patients per year are admitted from our

metro EDs unnecessarily• Approximately 45,000 bed days per year are filled with

patients waiting for intermediate resources to become available

• If we devote adequate resources to intermediate resources our acute care metro hospitals could potentially treat up to 2,733 more patients per year without adding beds (based upon LOS of 9 days)

• If we devote adequate resources to intermediate resources ARTC could potentially treat up to 344 more patients per year without adding beds (based upon average LOS of 60 days)

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Our Crisis with psychiatric patients being stuck in EDs awaiting inpatient beds and our shortage of inpatient beds is significantly due to lack of:

– Housing with supportive services (ranging from a relatively unskilled person available to talk with and remind patient to take meds up to facilities with more intensive programming and ability to manage meds)

– Places for patients with both substance abuse and mental health problems (with various attached services ranging from nothing i.e.. sober house to intensive treatment with lodging)

– Inefficiencies built into commitment process– Facilities able to serve patients with both MH and medical

needs– Timely access to out patient psychiatry (and other advanced

practice providers)10

• Study also highlights the lack of communication and coordination between hospitals and community social services

• Study highlights the need for hospital clinicians and county social service providers to develop a common language, sense of responsibility/liability and jointly create more nuanced services based upon clinical need instead of traditional ways of bundling and paying for services.

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Strategies/Efforts to Improve

• Outpatient• Access

• DIAMOND/Collaborative Care• Integrated Care

• MHDAP• Enhanced Crisis Team• ACT• Adult Psychiatric Urgent Care Center/MHCA

• Inpatient• Emergency Departments• Inpatient Psychiatry – NQA & PADs• Commitment Process• Collaborative to Improve Commitment Process• Regions Efforts

• Intermediate Resources• IRTS/Foster Care/Crisis Beds• Partial Hospitalization

• Transition Efforts• BH RARE• In-Reach Social Worker 12

Enhanced Crisis Stabilization Team and Impact

1. Impact of our Mental Health Drug Assistance Program (MHDAP). MDAP was established in 2008 by the East Metro Mental Health Roundtable to help patients

with mental illnesses and substance use disorders who were unable to get necessary psychotropic medications. It covers the cost of medications, co-pays, or deductibles for up 3 months (1 month at a time) AND helps eligible patients actually apply and get on insurance products so they can reliably access meds in the future. Over the years, it has:

    Helped 1,404 patients access necessary medications Spent approximately $207,000 per year Roughly 15% of patients had insurance Of the initially uninsured, 72% had insurance (and were able to get meds) when leaving

the program 10% of participants needed help with co-pays, deductibles, or Medicare spend-down/gap

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       Hospital Psych 17% Hospital Psych 4%Hospital Physical 4% Hospital Physical 2%Homeless 14% Homeless 4%Employed 20% Employed 19%In Jail 6% In Jail 1%In Detox/CD Tx 8% In Detox/CD Tx 4%Thoughts  Harm Self 22% Thoughts Harm Self 8%Thoughts Harm Others

16% Thoughts Harm Others

3%

Access Free Meds 23% Access Free Meds 100%Missed Meds b/c Funds

58% Missed Meds b/c Funds

20%

# Participants  1485 # Participants 368

Prior to Starting MHDAP At end of MHDAP (60 days later for most patients)

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Adult Psychiatric Urgent Care Satisfaction Survey

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East Metro Emergency Departments

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5. Total behavioral health patient visits in emergency department: 2010-2013

Hospital 2010 2011  2012 2013 2014

Regions – ER Crisis Program

6,664 6,903 7,034 7,482 7,550

St. Joseph’s 1,119 1,463 1,424 1,343 -

United 2,113 2,438 3,016 1065 -

Combined 9,664 10,704 11,156 N/A -

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In-Reach Social Worker - Outcomes

Referrals County of ResidenceRegions = 21 Ramsey = 23St. Joes = 2 Henn = 1United = 2 Dakota = 1 HousingAt Intake - 40% Homeless or Couch HoppingAt Close - 33% Homeless or Couch Hopping

Insurance16% uninsured at intake 5% uninsured at close  Medical Provider72% had medical provider at opening90% had medical provider at closing Psychiatry48% had psychiatry at opening91% had psychiatry at closing

ER VisitsTotal ER Visits 6 months Prior = 306; Avg 12.2 Total ER Visits During In-reach = 95; Avg 3.8 Total ER Visits 6 months post = Data incomplete, but a dramatic reduction for those we were able to track

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Non-Qualified Admissions (NQAs)

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Common Reasons for PADs (Regions, 2014

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PADs for BH patients - Regions

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2009 2010 2011 2012 2013 Jan-July2014

Number of PADs 1110 2010 1743 1450 2675 1887

Percentage of PADs 25% 22.9% 19.0% 15.3% 19.9% 19.7%

Note:  This source of hospital data looks at PADs for patients who are insured through a HealthPartners health plan only. This is roughly 13% of Region’s behavioral health inpatient population.

72 Hour Holds from ER Crisis Program to BH Units

Commitment Process

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Hovander House

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Anoka Metro Regional Treatment Center (AMRTC)

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Reducing Re-Admissions (white Paper)

http://www.rarereadmissions.org/resources/mental_health.html

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QUESTIONS

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Upcoming RARE Events….

RARE MH Collaborative Final Learning DayTuesday February 24, 2015

9:00am – 3:30pm

Maplewood Community Center2100 White Bear Avenue, Maplewood, MN

Registration now open!Register here

Future webinars…

To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Networking Webinars, contact:

Kathy Cummings, kcummings@icsi.org

Jill Kemper, jkemper@icsi.org