Challenging Personalities: Multi-disciplinary Strategies to Care for Hospitalized Patients With Difficult Behaviors

Walter Polashenski, MDAssociate Chief of Medicine, Rochester General HospitalDivision Head of Rochester General Hospitalist GroupMichele Beeley, LCSW-RManager of Social Work Services, Rochester General HospitalAnil Job, MDDirector of Integration, Rochester General Hospitalist Group Lauren Van IngenSr. Administrative Assistant - DSRIP & Care Management

Required Content: Learning Objectives

• Discuss the challenges of dealing with behavioral health issues in the medical/surgical environment.

• Articulate the structure and goals of a behavioral management team.

• Describe the elements of an effective care plan for patients with behavioral challenges

Harried Hospital Staff

Harried Hospital Staff

Disgruntled Patient

Harried Hospital Staff

Disgruntled Patient

Conflict

Unmet expectations Maladaptive behaviors Substance abuse Illegal activities Disempowerment

Conflict

PatientDissatisfaction

StaffMorale

Unnecessary Utilization

Medical Errors

Conflict

PatientDissatisfaction

StaffMorale

Unnecessary Utilization

Medical Errors

The Behavioral Management Team

INDEX PATIENT

Index Patient Spring 2015

• RCA for a fall with Injury– Fall in the context of a disagreement with her nurse over timing of

pain medication– 47yo woman admitted for mild dyspnea related to volume overload.– Long standing dialysis. Long standing anticoagulation for recurrent

blood clots– 28 day hospital stay for factitious fever (22 days of unexplained fever)– Manipulating her heparin drip– Emotional outbursts over control of her care– General recognition that this type of situation is not unique.

– Something must be done to help hospital staff recognize and care for patients with challenging behaviors….

Something Has to be Done…

How do we utilize our collected information to create institutional memory for our care of challenging patients?

How do we re-direct our patients with disruptive behaviors into more productive interactions?

How do we protect our staff from burnout?

How do we provide higher value in caring for patients with disruptive behaviors?

Something Has to be Done…RCA Action Planning Session – Executive and Senior Leadership

• Developed a working definition of challenging behavior

• Challenging behavior profile patients: high volume of admissions, longer

LOS, high resource utilization, increased opportunity for error

• Acknowledged that staff may not know how to handle these behaviors

• Identified that there is a small but well-defined patient population with

similar characteristics to index patient

- Risk Management- Psychiatry- Transitional Housing- Care Management

(Community)

- Emergency Department- Guests

Multidisciplinary Team- Internal Medicine- Nursing- Social Work- Care Management

- (Inpatient)- Health Home- Behavioral Health- Patient Safety/Quality- Ethics

Enter the Behavioral Management Team (BMT)

What Does the BMT Do? Meet twice a month for 1 hour Cases are referred to a team email by anyone in the system

BehavioralMgtTeam@rochesterregional.org Reviewed for appropriateness and priority by the steering

team Internal Medicine, Nursing, Psychiatry, Social Work/Care

Management, Patient Safety & Quality Relevant parts of the chart reviewed beforehand and

presented Roundtable discussion Care plan, in the form of relevant prior history and important

“hints” for ongoing care, formulated and entered into the medical record

Meeting Agenda

Review Medical History Behavior History Family Dynamics/Social Situation

Determine Inpatient plan (medical management) Behavioral plan Discharge needs Readmission reduction plan

After the Meeting

Designated BMT Coordinator writes up plan from meeting and distributes for steering team review

Steering team amends plan as needed

Once final, plan is placed in electronic medical record so all clinical staff can review when needed

Flag in Electronic Medical Record

Track Board

BMT patients are added to a shared patient list in the EMR

Allows team to have a snapshot of who is currently admitted, as well as their most recent admission

Goals of BMT Plan

Consistent messaging to the staff and the patient

Consistent floor for nursing care

Institutional awareness of patient’s prior history

Clear cut method of escalating for staff

Improved care for the patient

More Examples

Case Two - Summary

• 34 year old man with 10 ED visits in 5 months for “infected wounds”

• Violent behavior when admitted, particularly around decision to discharge.

• Suicidal threats when not given pain medications• Evidence of self-mutilation to obtain medications• Using “make-up” to make wounds look worse

than they are.

Case Two9:00 AM 9:15 AM

Example of a Behavioral PlanMedical History: • 35 year old with depression, PTSD, antisocial personality disorder• Presents to ED mainly for cutting himself. Suspect that he is there for

pain meds.• Has been seen by a psychiatrist in the community who prescribed him

Klonopin 1 mg 4x daily• Frequently admitted for "wound infections" that he will state are "failing

oral therapy“– images of wounds in record suggest mild infections

• Wounds often won't heal properly as patient picks at them, removes sutures, and does not take care of them.

• Has been prescribed oxycodone on a regular basis from local EDs• Circulates between the local hospitals to see where he can get admitted

and obtain meds

Example of a Behavioral Plan

Behavior History:• Can be aggressive when he does not get his pain meds• Threatens suicide to stay in hospital but has no history

of actual suicide attempts– psychiatry opinion in past has been that these threats are

manipulative• Regularly changes stories as to how injuries are

obtained• Mar 2016-used make-up or face paint to simulate the

findings of cellulitis to get admission.

Example of a Behavioral PlanInpatient Plan: • Admission criteria: admit for active signs of infection that

require IV antibiotics– "Failing outpatient therapy" is generally not sufficient (i.e. he

is likely not taking meds, or is causing injury to delay healing)• Suggest to always have nursing clean skin around wound

prior to admission (see Mar 2, 2016 admission)• Suggest no benzos; but if must use, administer 2x daily at

most• Avoid IV narcotics• Photo document his wounds at beginning and end of

hospitalization and put in patient chart

Example of a Behavioral Plan

Behavior Plan:• Staff to be firm and warn him that we will press

charges for harassment if he threatens the medical team

• Do not bargain with his suicide threats• Do not use 1:1 for suicidal threats, only use if

medically indicated• If threatens suicide to avoid discharge, obtain quick

psych consult• Have Security present at time of his discharge as he

may become aggressive

Example of a Behavioral Plan

Discharge Needs:• Address homelessness, does he have anywhere to go?

Note that he is adamant about not going to a shelter

Readmission Reduction Plan: • Contact outpatient psychiatrist and work in conjunction

with him. Consider decreasing Klonopin• Is he actually a veteran? If so could link with VA services.• Refer to Inpatient Chemical Dependency

Example of a Behavioral Plan

Family Dynamics:• Homeless; was staying with a friend's father but stole

money from that household and is not welcome back • Has some family (2 children) in Buffalo but no contact• Had a couple of friends visit him while in hospital.

Someone named Don, seems to care about his welfare.

• Possibly in jail recently

Example Three• 22 year old with paraplegia and traumatic brain injury after an

MVA. Repeated admissions for infected decubitus ulcers and wound care.– Abusive to nurses– Often refuses care, particularly dressing changes and then accuses

staff of neglecting him– Frequent requests to change physicians and/or nurses– Throws ostomy, food trays– Calls hospital operator and impersonates a physician, asking to be

connected directly to the personal cell phones of hospital physicians– Accuses staff of sexual harassment– Ranges from charming to hostile on any given day– Home pain medication regimen may not be adequate when he is

hospitalized

Example of a Behavioral ContractWhile you are hospitalized at ____________________ (fill in hospital) the staff will endeavor to be as sensitive to your needs as possible. Our goal is to provide you with the best care you will allow us to provide. In turn, we expect you will be courteous and respectful towards the staff who are caring for you. The following is a list of required behaviors:

• We believe that you have the ability to act in a cooperative and respectful manner.• You will be respectful of staff who are trying to provide care to you. You will not raise your voice or use

abusive language. You have the right to refuse care, but we expect you to do so in a calm and respectful manner.

• If you are verbally abusive, argumentative or raise your voice, staff has been instructed to leave the room until you are able to calm down.

• Security will be summoned if you remain verbally abusive.• You will not throw things at staff. The staff has been instructed to call the local police to press charges for

assault if you fail to comply with this provision.• You will not make direct phone calls to physicians or to any other care providers. You may not call the page

operator to page physicians to your phone. Impersonating a physician is a serious offense and will not be tolerated. If you wish to speak with a provider, you must utilize the normal channels to communicate—namely by asking your nurse to convey a message.

• Your phone will be confiscated if you do not comply with the above stipulation.• For your own safety, you may not change physicians during your hospitalization.

Review of Evidence

• Are patients with challenging interactions common?

• How do these interactions impact our ability to provide care?

Why do we care?

Challenging Patients Higher Morbidity/Mortality Higher costUnnecessary testingUnnecessary treatmentsExcessive LOS

Staff morale (burnout)Medical error (bias)

Why do we care?

Challenging Patients Higher Morbidity/Mortality Higher costUnnecessary testingUnnecessary treatmentsExcessive LOS

Staff morale (burnout)Medical error (bias)

Why do we care?

Challenging Patients Higher Morbidity/Mortality Higher costUnnecessary testingUnnecessary treatmentsExcessive LOS

Staff morale (burnout)Medical error (bias)

Characteristics of Frequently Admitted Patients

JHM; 2015; 10: 563-568.

Characteristics of Frequently Admitted Patients

• Frequently admitted patients were more likely to….

– Be Young (<65)– Have Medicaid or no insurance (although still 75% had

insurance)– Be admitted to a medical service– Be discharged to a skilled nursing facility or home with

home care– Have substance abuse or alcohol abuse issues– Have a diagnosis of psychosis or depression– Have multiple co-morbidities (congestive heart failure and

type 2 DM particularly)

Characteristics of Frequently Admitted Patients

JHM; 2015; 10: 563-568.

Medical Error--Limited Data

Do disruptive patients influence a physician’s diagnostic accuracy?

Disruptive patients: patients whose patterns of behavior or interactions with the medical system interfere with our ability to provide the highest quality care

Diagnostic Accuracy

63 family medicine residents 6 clinical vignettes with a known diagnosis Difficult patient version Neutral patient version 3 cases were considered “complex”; 3 cases

“simple” or straightforward

Each resident was asked to diagnose all six cases; randomly received the difficult or neutral version

BMJ Qual Saf 2016; 0: 1-5.

Diagnostic Accuracy

Difficult PatientBehaviors

Neutral Patient Behaviors

Complex 23% 40%Simple 88% 94%Overall 54% 64% P=.017

BMJ Qual Saf 2016; 0: 1-5.

Proportion of correct diagnoses

Do Multidisciplinary Teams Reduce Utilization or Improve Quality?

Multidisciplinary Teams Duke University: Aug 2012-2013

Complex Care Plan Committee (CCPC)

Eligible patients: > 3 ED visits/admissions, and “Some degree of medical, social or behavioral complexity”

Twenty-four patients 183 ED visits and 145 inpatient admissions for the 6 months

prior to enrollment

Multidisciplinary team to meet monthly to create individualized care plans

JHM 2015;10:419-24

Multidisciplinary Teams

Epic EMR Care plans available to all providers across

Duke Health System Colored banner to notify providers that a

plan exists Automated notification process Page to on-call admitting physician whenever

patient is registered in EDJHM 2015;10:419-24

Multidisciplinary Teams

Median Age 36 (25-65)

46% Medicare 38% Medicaid

Multitude of chronic illness Asthma, COPD, ESRD, CAD, DM, CHF 83% with a chronic pain issue 96% with either substance abuse or mental health issue

JHM 2015;10:419-24

Multidisciplinary Teams

JHM 2015;10:419-24

Before After

Total Admissions 145 56

Admissions/Patient 6.3 2.4 <0.001

Before After

Length of Stay 5.0 4.7 NS

Before After

ED Visits Total 183 198

ED Visit/Patient 8 8.6NS

Multidisciplinary Teams

Combined Costs reduced by 43% at 6 months

$15,117.30 per patient

Before After

Inpatient Cost/patient $29,852.71 $15,587.84

ED cost/patient $3,482.84 $2,630.45

Combined cost/patient $33,335.56 $18,218.30

What Changed for Rochester General After BMT?

Patient Identification

Referrals Referrals from multiple venues (ED, ambulatory,

physicians, nursing, CM, SW) 2-4 week waiting list for review

Good acceptance of plans from staff members Reasonably good visibility of plan Still working on optimal visibility

RGH BMT Preliminary Data July 2015 – October 2017 78 patients Mean Age: 48 (21-92) Median Age: 47 86% on Medicaid/Medicare

Themes: Substance abuse Chronic pain Mental health (particularly personality disorder) Homelessness High burden of illness (at least 11 deaths since team initiation)

RGH BMT Preliminary Data

Reviewed 78 Patients

Of those, 37 patients are in a timeframe to review 6 months before and after plan creation

47% of all patients reviewed

RGH BMT Data

Costs reduced by 52% per admission at 6 months 66% reduction in hospitalizations (IP and Obs

combined) Total cost reduction: $892,332

Before After

Inpatient Cost/admission $11,370.00 $5,514.00

Avg. Length of Stay 7.1 2.85

Combined admissions 94 32

Combined ED visits 140 98

Combined Obs visits 37 17

Future Plans

Consult team for urgent behavioral issues Combined hospital effects

Keys to Success

• Dedicated point of contact to coordinate the team

• Commitment of team members to meet at a regular frequency

• Way to share plans with all clinical staff

• Frequent follow up to support consistency of plan

• Data reporting to determine effectiveness of plans

Executive Summary

• It is possible to restructure/reframe difficult interactions with dedicated plans for staff to refer to

• Team members have expressed considerable satisfaction with the effect of plans

QUESTIONS?

References

Szekendi, MK, Williams, MV, Carrier, D, Hensley, L, Thomas, S, Cerese, J. The Characteristics of Patients Frequently Admitted to Academic Medical Centers in the United States. JHM; 2015; 10: 563-568.

C. Boyd, B. Leff, C. Weiss, J. Wolff, R. Clark, and T. Richards. Full Report: Clarifying Multimorbidity to Improve Targeting and Delivery of Clinical Services for Medicaid Populations. Center for Health Care Strategies, Inc., December 2010.

Redelmeier DA, Etchells EE. Unwanted patients and unwanted diagnostic errors. BMJ Qual Saf 2016;0:1–3.

Mercer, Tim; Bae, Jon; Kipnes, Joanna; Velazquez, Maureen; Thomas, Samantha; Setji, Noppon. The Highest Utilizers of Care: Individual Care Plans to Coordinate Care, Improve Healthcare Service Utilization, and Reduce Costs at an Academic Tertiary Care Center. Journal of Hospital Medicine. 10(7): 419-424. 2015 July.

Althaus, F., Paroz, S., Hugli, O., Ghali, W.A., Daeppen, J.B., Peytremann-Bridevaux, I., Bodenmann, P. Effectiveness of interventions targeting frequent users of emergency departments: a systematic review. Ann Emerg Med. 2011 Jul; 58(1):41-52.