DevelopingaHospital-BasedPerformanceImprovementProjecttoReduce30-Day

PsychiatricReadmissionsatUTHealthHarrisCountyPsychiatricCenter

JaneHamilton,Ph.D.,M.P.H.,L.C.S.W.,AssistantProfessorOliviaMoffitt,M.D.,PsychiatryResident

McGovernMedicalSchool,DepartmentofPsychiatryandBehavioralSciences

ImpactingPopulationHealth• TheUniversityofTexas,HarrisCountyPsychiatricCenter(HCPC)isimplementingapopulationhealthapproach,interveningwithpatientsbothasindividualsandasmembersofapopulationwithseriousmentalillness.

• TheinitiativeincorporatespreviousresearchconductedatHCPCthatsuggestssomepopulationgroupsaremorevulnerabletoaparticularhealthoutcomethanothers.

• Usingthisapproach,HCPCisabletoidentifythehealthandsocialneedsofitspatientpopulationanddeterminehowbesttopreventormeetthoseneeds.

WhyExamine30-DayPsychiatricReadmissions?

• Healthcarereformestablishedthegoalofreducing30-dayreadmissionsacrossmedicalconditions.

• Increasedinterestin30-daypsychiatricreadmissionratesasqualityindicators.

• Internationallyacceptedindicatorofthequalityofinpatientcareaswellasthetransitiontocommunity-basedcareafterdischarge.

UTHealthHarrisCountyPsychiatricCenter(HCPC)• Academicsafety-netpsychiatrichospitalinHouston,Texas.• Approximately9,000 children,adolescents,andadultsareservedperyear.

• 276 beds,10 psychiatricunits,and20 attendingpsychiatrists.

• In1990,apatient’saveragelengthofstaywas27days.

• Today,ouraveragelengthofstayis7days.

• Manypatientsareinvoluntarilyadmittedthroughacourt-orderedcommitmentprocess.

HCPCPatientCharacteristics

PatientCharacteristic Percentage

Male 61%

Non-Hispanic White 41%

African American 41%

Hispanic 17%

Schizophrenia 28%

MajorDepression 28%

Bipolar Disorder 38%

Uninsured 85%

DischargedintoHomeless Shelters 33%

StatementoftheReadmissionsProblemChronicrecidivismandrapidreadmissionsareagrowingconcernatHCPCduetoincreasedcostsandlessthanoptimaloutcomes.

2016ReadmissionsData

AdmissionType HCPC BedDays Costs($530/BedDay)

30-DayReadmission 8,925 $4,730,250Super-Utilizers

(4+AdmissionsperYear)8,362 $4,431,860

Note:195 super-utilizerpatientsaccountedfor971 admissionsaccountingfor11% ofall2016admissions.

ReadmissionsResearchatHCPCStudy1: FactorsDifferentiallyAssociatedwithEarlyReadmissionataUniversityTeachingPsychiatricHospital.(HamiltonJ.E.etal.JournalofEvaluationinClinicalPractice.2015).

Study2: PredictorsofPsychiatricReadmissionamongPatientswithBipolarDisorderatanAcademicSafety-NetHospital.(HamiltonJ.E.etal.AustralianandNewZealandJournalofPsychiatry.2016).

Study3: Post-DischargeEngagementwithOutpatientMentalHealthServicesamongFemalePsychiatricPatientsReadmittedwithin30DaysofDischargeaMixed-MethodsAnalysis.(HamiltonJ.E.etal.InPreparation).

1st Study:FactorsDifferentiallyAssociatedwithEarlyReadmissionatHCPC

• Qualityimprovementinterviews(n=588)wereconductedwithpatientsreadmittingwithin30daysofHCPCdischargefromJanuary2001toNovember2010.

• Interviewdataweremergedwithelectronicmedicalrecorddata.

• Statisticalmodelingwasconductedtoidentifypredictorsofearlierreadmission:post-dischargedays1– 7anddays8– 14comparedto15– 30daysafterdischarge.

30-DayReadmissionPatientInterviewQuestionsMaritalstatus?

Employmentstatus?

Yearsofeducation?

Arresthistory?

Voluntary/Involuntarystatus?

Sincethehospitalization,hasthepatientbeenemployed?

Doespatienthavefinancialsupport?

Wheredidthepatientliveafterthelasthospitalization?

Whatisthepatient’sbeliefastowhys/hereturnedsoquickly?

Overallhelpfulnessofthelasthospitalstay?

Adherencewithpsychiatricmedication?

Whatispatient’soverallexperiencewithmedicationeffectiveness?

Whatispatient’soverallexperiencewithmedicationsideeffects?

Patient’saftercareagencyreferral?

Patient’sattendanceattheaftercareagency?

SignificantPredictorswithin7Days AdjustedOddsRatio

ElevatedMentalhealthSymptoms(BriefPsychiatricRatingScale)• Grandiosity• Suspiciousness

1.51.4

Inconsistent FinancialSupport 4.0

Readmitted before1st scheduledaftercareappointment

10.2

Missedfirstaftercareappointment 2.4

SignificantPredictors8- 14Days

HighSchoolDegree 1.9

Readmitted before1st scheduledaftercareappointment

2.5

PredictorsofPsychiatricReadmissionamongPatientswithBipolarDisorder

• StudyexaminedpredictorsofHCPCreadmissionwithin30days,90daysand1yearofdischarge.

• ConceptualmodeladaptedfromAndersen’sBehavioralModelofHealthServiceUse.

• Statisticalmodelingwasconductedinasampleof2443adultpatientswithbipolardisorderadmittedtoHCPCfromJanuarythroughDecember2013toexaminesignificantpredictorsofreadmission.

Andersen’sBehavioralModelofHealthServiceUse

Groupsfactorsassociatedwithhealthserviceutilizationintothreecategories:

• Predisposing(characteristicsoftheindividualincludingage,gender,race,maritalstatus)

• Enabling (systemorstructuralfactorsthatmakehealthserviceresourcesavailabletotheindividual)

• Need(severityofillness/clinicalfactors)

AndersenR,NewmanJF.SocietalandindividualdeterminantsofmedicalcareutilizationintheUnitedStates.MilbankMemorialFundQuarterly.1973;51,95–124.

AndersenRM.Revisitingthebehavioralmodelandaccesstomedicalcare:Doesitmatter?JournalofHealthandSocialBehavior.1995;36,1–10.

HCPCPatientswithBipolarDisorder

PredisposingFactors(Age,Gender,Race/Ethnicity,

MaritalStatus)

EnablingFactors(InsuranceStatus,Homelessness,PriorUtilization,Involuntary

Status)

NeedFactors(BipolarDisorderType,CurrentManicEpisode,GAFScore)

HCPCPsychiatricReadmission

ConceptualModel:Andersen’sBehavioralModelofHealthServiceUse

StudyResultsAcrossalltimeperiods,increasedreadmissionriskassociatedwith:

• Beinguninsured• 3ormorepsychiatrichospitalizations• AlowerGlobalAssessmentofFunctioning(GAF)score

Within30and90daysofdischarge,increasedreadmissionriskassociatedwithpatienthomelessness.

Within1yearofdischarge,increasedreadmissionriskassociatedwithmalegender.

SpecialPopulations:Examining30-DayPsychiatricReadmissionsamongWomenwithSeriousMentalIllness

StudyAims:Describefactorsinfluencing30-daypsychiatricreadmissionsamongwomenusingaSocialDeterminantsofHealthframework.

Methods:HCPCsocialworkersconducted60semi-structuredinterviewswithadultfemale30-dayreadmittedpatientsin2016.Medicalchartreviewswereconductedtosupplementtheinterviewdata.Interviewresultsaresharedwiththenewtreatmentteamtoinformcurrenttreatmentplanning.

TranslatingResearchtoPracticeGoals:Developatailoredinterventiontoimproveengagementwithoutpatientservicesandreducepsychiatricreadmissionsamongadultfemalepatients.

PatientInterviewForm:30-DayPsychiatricReadmissions

MedicalRecordNumber:____________NumberofDaysbetweenHospitalizations:___________Involuntary:Y□ N□ Homeless:Y□ N□

Whatispatient’sbeliefastowhys/hereturnedsoquicklytothehospital?(Checkallthatapply)□ Patientwasn’treadytoleaveduringprevioushospitalization□ Medicationproblems□ Livingsituationafterdischargewasstressful(environmentalstressors)□ Other

Y□ N□ Didpatientattendanyaftercareappointments?(Ifno,pleaseanswerthenextquestion).

Patient’sdescriptionwhys/hedidnotattendaftercareappointments(pleasedescribeinpatient’sownwordsusingquotationmarks):

Ifpatientdidattendaftercare(pleasedescribeinpatient’sownwordswhatfactorshelpedwithsuccessfulengagement):

Y□ N□ Wastherepost-dischargesubstanceabuse?

Patient’sdescriptionofwhatledtothisreadmission(pleasedescribeinpatient’sownwordsusingquotationmarks):

PreviousSocialServicesclinician’sperceptionoffactorsleadingtothisreadmission(pleasedescribeinsocialworker’sownwordsusingquotationmarks):

30-dayReadmissionInterviewResults

Only12% ofadultfemalepatientsinterviewedreportedattendinganaftercareappointmentpriortoreadmission.

43% reportedusingsubstancesafterdischarge.

PatientReportedBeliefsaboutReasonsforReadmission37%reportedhavingmedicationproblemsafterdischarge.40%reportedlivinginastressfulenvironmentafterdischarge.

Chartreviewsrevealedthemajorityofpatientsinterviewedhad4+HCPCadmissionsandwereunemployed,homeless,uninsured,andinvoluntarilyreadmitted.

FocusGroupswithHCPCPatientstoTailorReadmissionsReductionInterventions

In2016,weconductedtwofocusgroupsontheHCPCSchizophreniaUnittoobtainpatient-reportedinformationon:• Interventionneedsandpreferences.• Barriersandfacilitatorstopost-dischargeengagementinoutpatientservices.

ThemesEmergingfromFocusGroupData

• Patientsexhibitedlowlevelsofhealthliteracyandreportedlackingunderstandingoftheirmentalillnessesanddischargeplans.

• Patientsreporteddifficultiesaccessingpsychiatricmedicationsandattendingscheduledappointments.

DevelopingaHospital-BasedPerformanceImprovementProjectto

Reduce30-DayPsychiatricReadmissionsatHCPC

TranslatingResearchtoPracticeOurresearchenabledustoidentifypriorityareasforimplementingstrategiestoreduce30-dayreadmissionsandtointervenewithsuper-utilizers.

• MedicationAdherence• EngagementinPost-DischargeOutpatientServices• SubstanceUse• HousingInstability/Homelessness

Basedonthesepriorityareas,weareleveragingexistinghospitalresourcestoimplementevidence-basedinterventionsandarecreatingcommunitypartnershipstoreducereadmissions.

LeveragingtheHCPCElectronicHealthRecord(EHR)toIdentifyHigh-RiskPatientsthroughRiskStratificationAnalertsystemisbeingimplementedintheEHRtotargetthefollowingpatients:• Patientsatriskfor30-dayreadmissions• Super-utilizerpatients(4+HCPCadmissionsin1Year)• Homelesspatients

Weconductedasystematicreviewofthepsychiatricreadmissionsliteraturetoidentifyreadmissionsriskfactors(n=18studies).

7 studiesfoundapositiverelationshipbetweenagreaternumberofpreviouspsychiatrichospitalizationsandreadmissionwithin30daysofdischarge.Applebyetal.,1993;Swett,1995;NicolsonandFeinstein,1996;Monnelly,1997;Zilber,Hornik-Lurie,Lerner,2011;Kreys etal.2013;Hamiltonetal.,2015.

PriorityArea Intervention

MedicationAdherenceSharedDecisionMakingTeach-BackMedication Reconciliation

PatientEngagementMotivationalInterviewingIntensiveCaseReviews

SubstanceUse

Inpatient SubstanceUseGroupsPatient andFamilyPsychoeducationReferralsto evidence-basedservices

HomelessnessSupported HousingReferralsto evidence-basedservices

InterventionMappingHesselinketal.BMCHealthServicesResearch2014

SharedDecisionMaking(SDM)ThePinnacleofPatient-CenteredCare

Aprovider’sroleinSDMisto:• Educatepatientsaboutallavailabletreatments.• Acknowledgeandhelpclarifypatientpreferencesandvalues.• Empowerpatientstotakeanactiveroleinthedecision-makingprocess.

• Theonlypreferencedrivingvariationsincareshouldbethatofthepatient.

• SDMisassociatedwithdecreasedanxiety,quickerrecovery,andincreasedtreatmentadherence.

• SDMinnovationsincludeelectronicdecisionaidsandinteractivetechnologiestoprovidepatienteducation.

StrategiesforImprovingPatientExperiencewithAmbulatoryCare.(2016)AgencyforHealthcareResearchandQuality,Rockville,MD.

Teach-BackTeach-Backisanevidence-basedhealthliteracyinterventionthatpromotesadherence,quality,andpatientsafety.

Patientsareaskedinasupportivemannertoexplain,intheirownwords,whattheyneedtoknow,ordo,afterdischargeasawaytocheckforunderstandingandtore-explaindischargeinstructionsifneeded.

AtHCPC,Teach-Backtechniquesareutilizedbytreatmentteammemberstoensure:• patientsunderstandmedicationinstructionsanddosage.• patientsunderstandtheiraftercareplansandhavesupportsinplacetoattendaftercareappointments.

http://www.teachbacktraining.org/

PeterD,RobinsonP,JordanM,LawrenceS,CaseyK,Salas-LopezD.Reducingreadmissionsusingteach-back:enhancingpatientandfamilyeducation.JNurs Adm.2015;45(1):35-42.

MedicationBestPracticesMedicationReconciliation• Processofcomparingapatient'smedicationorderstoallmedicationsthepatienthasbeentaking.

• Allpatientsreceivedetailedinformationaboutmedications.• Teach-backtechniquesareutilizedtoensurepatientsunderstandmedicationinstructions.

• Detailedinformationisprovidedtooutpatientprovidersandcaregiversasneeded.

MedicationFillandCounselingatDischarge• Patientsareprovidedwithfilledpsychiatricprescriptionsandmedicationcounselingfromthepharmacist,whichhasbeenassociatedwithreducedreadmissions.

TomkoJR,AhmedN,MukherjeeK,RomaRS,DilucenteD,OrchowskiK.Evaluationofadischargemedicationserviceonanacutepsychiatricunit.HospitalPharmacy.2013;48(4):314-320.

MotivationalInterviewing(MI)MIisapatientengagement,motivationalenhancement,andcounselingprocesswidelyusedinmentalhealthandsubstanceabusetreatment.

A1-hourMIsessionconductedpriortopsychiatrichospitaldischargehasbeenshowninpriorresearchtoimproveattendanceatthe1stoutpatientappointmentcomparedtotreatmentasusual.

HCPCpsychiatryresidents,socialworkersandpharmacistsaretrainedinMItechniquesusingtheOARSapproach(open-endedquestions,affirmations,reflectivelistening,andsummarizing).

AMIscriptthataddressestreatmentengagementandmedicationadherenceissuesisbeingpilotedatHCPC.

SwansonAJ,PantalonMV,CohenKR.MotivationalInterviewingandTreatmentAdherenceamongPsychiatricandDuallyDiagnosedPatients.JournalofNervous&MentalDisease.1999;187(10):630-635.

HCPC2016PilotInterventionsIn2016,evidence-basedinterventionswereimplementedwithpatientsfromoneofthetwotreatmentteamsontheHCPCSchizophreniaUnit(secondtreatmentteampatientsservedascontrols).

Theinterventiongroup(n=615)comparedtothecontrolgroup(n=513)hadreduced30-dayreadmissions(14%vs.20%;chi-square5.914;p=0.015).

SchizophreniaUnit2015

ReadmissionRate2016

ReadmissionRate

Intervention Group 17% 14%

ControlGroup 15% 20%

ProgramEvaluationMethods• Aspartoftheprogramevaluation,aRootCauseAnalysis (RCA)willbeconducted.

• TheRCAgoalistoidentifythefactorsresultinginHCPCreadmissionstodeterminewhatactionsand/orinactionsneedtobechangedtoreducereadmissionsandtoidentifylessonslearnedforfutureplanning.

• RCAwillprovidevaluableinformationaboutsystems-levelfactorsandsupportsleadingtoreadmissionsincludingwhypatientsarenon-adherentandbarrierstooutpatientengagement.

• Datatobeexaminedincludes:HCPCelectronicmedicalrecordandpatientandproviderinterviewdata.

Wilson,PaulF.;Dell,LarryD.;Anderson,GaylordF.(1993). RootCauseAnalysis:AToolforTotalQualityManagement.Milwaukee,Wisconsin:ASQQualityPress.pp. 8–17.

NewYorkStateOfficeofMentalHealth.ReducingBehavioralHealthReadmissions:StrategiesandLessonsLearned

MultidisciplinaryApproach• Therearemultipleopportunitiesforqualityimprovementinpsychiatricservices.

• Giventhecomplexnatureofseriousmentalillness(SMI)andthevulnerabilityoftheSMIpopulation,multidisciplinarycollaborationisvitaltothesuccessofourinitiative.

• Ourgoalistodevelopamultidisciplinaryapproachforourperformanceimprovementprojects:• EngagingallHCPCdisciplines/departmentsinthePIprojects• CreateaHCPCfaculty/staffworkgroupforeachPIproject• InvolvingHCPCfacultyphysiciansandpsychiatryresidentsinqualityresearch

ResearchCollaborators

Q&A