INNOVATIONS IN BEHAVIORAL HEALTH

December 10, 2013

Webinar Agenda

Welcome

Danielle Lazar, Senior Research Associate, Urgent Matters

Behavioral Health and Detoxification: Meeting Demand for Services

Michael A. Turturro MD, FACEP, Associate Professor of Emergency Medicine, University of Pittsburgh School of Medicine, Chief of Emergency Services, UPMC-Mercy, Pittsburgh, PA

Upstream Crisis Intervention

Michael Coleman, MPA, Director of EMS Operations at Grady Health Systems, Atlanta, GA

Behavioral Health and

Detoxification:

Meeting Demand for

Services

Michael A. Turturro MD, FACEP

Associate Professor of Emergency Medicine

University of Pittsburgh School of Medicine

Chief of Emergency Services, UPMC-Mercy

Pittsburgh, PA

The Setup

UPMC-Mercy 433 Inpatient Beds

34 Behavioral Health Beds

18 Medically-managed Inpatient Detox Beds

Level I Trauma Center, Urban

73,000 ED visits/year

29 General Beds

2 Bed Trauma Resuscitation Bay

5 Bed Fast Track

17 Bed CDU

Behavioral Health Intake Evaluation Area (ERC) –

Capacity 13

Background

Nationally: decrease in inpatient and long-term

behavioral health bed availability

Efforts to increase care in the community have

not filled this void

Funding decreasing for behavioral health and

addiction services

Acute med-surg hospitals caught in the middle,

often ill-equipped

Utilization of community resources often not

optimized

Background

ED volumes increasing

Lack of specialized services to EDs

Risk of adverse events

Regulatory barriers to care

The Setup

2002-2008: Closure of inpatient behavioral

health units in 5 hospitals within Allegheny

County

December 2008: 350 bed state run regional long

term behavioral health facility closed by

Commonwealth of PA

Discharged into less restrictive, community-based

settings "to reduce reliance on institutional care and

improve access to home and community-based

services for Pennsylvanians living with mental

illness”

The Setup

January 2009-June 2012

ED volume increased 22%

Visits for behavioral health/detox increased 325%

2009: 2173 visits

2012: 6689 visits

Admission rate increased 95% with no increase in

capacity

Nearly 80% of visits could be managed in a less

restrictive setting than inpatient

The Setup

End Result

Delays in patient evaluation

Boarding of admitted behavioral health patients in

the ED, medical floors

Exacerbation of hospital crowding

Hospital expenditures on staff to “babysit” patients

Staff dissatisfaction

Intervention

Organization of stakeholders within the hospital

and community

Emergency Medicine

Psychiatry

Addiction Medicine

Hospitalists

Nursing

Hospital Administration/Support Staff

Goals

Optimize safe alternatives to hospitalization

Streamline inpatient care to facilitate capacity

Specific Tactics: Aug 2012- Jan 2013

Partnership with competing behavioral health

facilities

Manage volume regionally rather in silos

No-hassle transfers facilitated

Secure outpatient appointments

Within 1 week of ED or inpatient stay

Referrals to partial and respite programs

Specific Tactics: Aug 2012- Jan 2013

Partnership with community-based crisis

intervention center (ReSolve)

Conversion of ERC RN positions to crisis clinician

positions

Serve as first point of contact for behavioral health

patients 16 hrs/day

Structured suicide risk assessment

Link to community resources (housing, food banks,

transport services, etc.)

Goal: patient remain in the community whenever

possible

Specific Tactics: Aug 2012- Jan 2013

Conversion of ERC RN position to detox

clinician position

Dedicated space in the ED for evaluations 16

hours/day

Structured referrals to ambulatory and inpatient

detoxification and rehabilitation programs

Evaluate in parallel to ED evaluation rather than

sequential

Specific Tactics: Aug 2012- Jan 2013

Inpatient

Utilization review training: ERC and inpatient

behavioral health staff

Post discharge planning on hospital day 1

Training of inpatient staff in detoxification

assessment and treatment

Transition from inpatient to outpatient treatment of

opioid detoxification

Transition from phenobarbital taper to symptom-

triggered treatment for ETOH withdrawal (inpatient

LOS reduction tactic)

Results: Detoxification Detox RNs evaluated >300 pts/month

10-fold increased in outpatient referrals from 1st quarter

CY 2012 to 1st quarter CY 2013

Decrease in detox 30-day recidivism from 17% to 10%

Mean wait time for detox evaluation

May 2012: 68 minutes

May 2013: 18 minutes

Mean ED length of stay for admitted patients

May 2012: 17 hours

May 2013: 9 hours

Mean ED length of stay for discharged patients

May 2012: 9 hours

May 2013: 6 hours

Results: Behavioral Health

Crisis clinicians evaluated ~100 pts/month

81% increase in transfers to available beds from 1st

quarter CY 2012 to 1st quarter CY 2013

160% increase in referrals to non-hospital programs

from 1st quarter CY 2012 to 1st quarter CY 2013

Mean wait time for behavioral health evaluation

May 2012: 67 minutes

May 2013: 11 minutes

ED length of stay for admitted patients

May 2012: 34 hours

May 2013: 11 hours

Costs/Benefits

Conversion of RN to crisis clinician position =

33% saving in salary/benefits

Decrease in RN time spent managing behavioral

health/detox patients

Decrease in expenditures on sitters house-wide

Facilitation of outpatient care decrease in ED

visits

Change in care delivery decreased need for

staffing sustainability

Further Opportunities

Overnight ReSolve/Detox RN staffing

Enhancing psychiatry coverage (ED and

hospital)

On-site sobering center for intoxicated patients

Development of a State-wide bed tracking

system

Modeled after Maryland

Co-sponsored by PaACEP and PaPS

PA Medical Society Resolution Adopted

Advice

Get all stakeholders involved early and often

Investigate, then engage all community

resources

Eliminate competitive barriers/silos

Grady EMS Grady Health System, Atlanta GA.

Upstream Crisis Intervention

Vision Grady Health System will become the leading public academic healthcare

system in the United States

Michael Colman, MPA, NRP, Director of EMS Operations at Grady Health Systems

Arthur H. Yancey, II, MD, MPH, FACEP, Associate Professor Department of Emergency

Medicine Emory University School of Medicine and Grady EMS Medical Director

Grady EMS Atlanta Ga.

• In 2012 Grady EMS encountered 5,807 psychiatric related calls based on the paramedic’s Provider Impression of Anxiety, Behavioral Disorder, Depression, and Psychiatric Emergency.

• Ninety (90) percent of psychiatric patients encountered by Grady EMS did not require admission

• Expense

– ER-the ED average loss per patient was -$401

– EMS average loss per ambulance transport was- $109.

Grady Health System

• Fifty (50) percent of psychiatric patients registered at Grady’s ED were ultimately discharged with a referral and/or appointment for outpatient care.

• This program design to move this discharge disposition ‘upstream’ into the EMS field

Background

• 3 week pilot program began in Jan 2013

• Involved: EMS leadership, senior hospital leadership to the CEO level, Medical Direction from EMS, physician partnership from psychiatry, partnership with BHL to provide a social worker with expertise in mental health and a background of working on a mobile crisis unit.

• Pilot never ended.

Grady Health System

Grady EMS Prehospital Paramedicine

Clinical Alternate Destination Program

Alternate Pathway

Decrease Attrition and Paramedic burnout

Decrease Overtime

Decrease Unit Hour Utilization (UHU)

Decrease need for additional 911-ALS ambulances

* Prorated projected number for 2013

** These calls now fall under Nurse Advice.

*** When Nurse Advice projections met, BLS will decrease

BLS Tiered

Response

2011

2012- 153

2013**-30

Non-Emergency

Transportation

911-ALS Response

Nurse Advice Call

Center

2012

Ambulances Transport to

Neighborhood Health

2010

Crisis Intervention

Unit

2013

2012- 3,932

2013-12,000* ***

2012- 1,513

2013- 8,000* 2013- 884*

2012 Decrease in 911-ALS Responses

5,598

Projected Annual Decrease in 911-ALS Responses

18,914

Projected Annual Savings to Grady Health System

$1,084,020

Phases

• Prior to Pilot (Officer forms and law enforcement, 08/2012)

• Part 1 (the Pilot Team, 01/2013)

• Part 2: (GCAL referrals directly from EMS crews, 02/2013)

• Part 3 (MOU to transfer first party callers directly to G.C.A.L.)

• Part 4 (Expansion of ADP, 04/2013)

• Part 5 (Sole responding unit, 04/2013)

• Part 6 (Alteration of hours, 06/2013)

• Part 7 (Unscheduled and Scheduled home visits, 08/2013)

• Part 8 (doubled staffing to 80-hours per week, 08/2013)

Prior to Pilot

(Officer forms and law enforcement, 08/2012)

• Grady EMS met with an Atlanta Police Department (APD) Deputy Chief and other senior leaders at the Zone levels

• Grady EMS reviewed the Officer Forms and APD policy in reference to Peace Officers taking a person into custody for mental health concerns

• Grady EMS adopted language from the APD policy to create a mirror so both agencies would have a common understanding of the process

• Grady EMS and APD reviewed the policy with all staff because even though the policies existed, they had not been executed in many years

Part 1

(the Pilot Team, 01/2013) • Grady EMS SUV co-respond with an ambulance.

• Triaged through the National Academy of Emergency Medical Dispatch NAEMD category 25 (psychiatric / suicide attempt),

• Crew consisted of: Grady EMS paramedic, a Grady Behavioral Heath Licensed Professional Counselor (LPC), and a BHL Licensed Clinical Social Worker (LCSW) or LPC from their mobile crisis unit. – Additionally, on some shifts a psychiatry PGY3 from Morehouse.

Part 2:

(GCAL referrals directly from EMS crews,02/2013)

• Training session to provide overview of Georgia Crisis and Access Line (GCAL).

• Provided medics with business cards

• Medics called number and advised the clinician it was a referral and handed phone to pt.

• Used when crisis team not available.

Part 3 (MOU to transfer first party callers to G.C.A.L.)

• Grady EMS finalized an MOU with GCAL on February 16, 2013.

• Implemented in April 2013.

• Allowed our 911 call center (PSAP) to directly transfer specific psychiatric triaged calls (NAEMD 25-omega) to GCAL.

• Grady’s 911 center has transferred 70 calls to GCAL.

• No ambulance responded

Part 4

(Expansion to offer ADP, 04/2013) • The crisis team transported patients to in-

patient psychiatric facilities

• Medics contacted EMS Medical Director or EMS Fellow for screening and approval.

– Assure safety of the program, regarding appropriate patient dispositions from the field, without under triage of patients with emergency conditions who were not dispositioned to the ED.

Grady EMS Upstream Crisis Intervention Unit Alternate Destination Program

Ambulance or 7070

Transport to ED

Courtesy ride to

pharmacy, shelter,

etc.

Paramedic Medical Evaluation

BHL Mental Health Evaluation

Transport to in-patient

psychiatric or substance abuse

facility

Refusal; GCAL

Card, Outpatient

Appointment

Direct Admit transport

to in-patient bed

located at a hospital

with an ED:

EMS Supervisor

Notification BHL confirms bed acceptance

EMS Medical Director

Notification for ADP Approval

Dr. Yancey 404-985-7248

Dr. Bloom 404-686-1000

PET TEAM DIRECT #

AMC-N: 404-265-1200

AMC-S: 404-266-2645

Unscheduled or Scheduled

home visit

Non-911 initiated response

Investigate opportunities

to decrease 911 use.

(Referral to ACT.

Medication, pharmacy,

housing, or other needs)

Part 5

(Sole responding unit, 04/2013) • Altered response to eliminate ambulance

response with team.

Part 6

(Alteration of hours, 06/2013) • Based on call demand

• Two week evaluation of a night shift

Part 7

(Unscheduled and Scheduled home visits, 08/2013)

• Integration of a Community Paramedic program for pts with mental health issues

• Pts identified through high user lists

• QA department screened charts (EMS/ER) to determine optimal cases.

• Prevent from misusing EMS and ER

Part 7 (Unscheduled and Scheduled home visits, 08/2013)

• What was offered pts – Transport to obtain medications

– Transport to appointments

– Scheduled appointments

– Coordinated pharmacy efforts

– Checked medications bottles for compliance

– Follow-up to assure they are going to appointment or medications were obtained.

– In-service training to family members to administer prescribed injections of psych meds.

– Engaged family members to call when pt arrives.

– Provided team with a cell phone for pts to make direct contact

– Reconnect pts with their providers; medical or mental health

– Given family members GCAL cards

Part 7 Continued (Unscheduled and Scheduled home visits, 08/2013)

– Provide family members support with referral option and team cell number

– Connect pts with ACT team and case managers

– Transport pts to shelter or secondary residence

– Transport pts to a caregiver or better support system

– Remove pts from location that is escalating and transporting to a secondary location.

– Worked to place a homeless pt into a nursing home

– Worked to secure temporary housing

– Worked with case management at hospital to investigate eligibility to receive benefits (Medicaid or other discount)

– Transport to hospital to appointment with financial counseling

– WHAT EVER IT TAKES to help the pt with mental health

– Many cases of pts calling 911 more than 5 times per month going to zero after home visits.

Data

Calls transferred to GCAL- no 911 response- 70

911 responses by psych unit- 01/14-11/30/13 1124

Unscheduled home visits attempts/phone contact 116

Unscheduled home visits- patient contact 34

Refusal, no transport- 248

Cancellations, no pt found-EMS not needed- 183

Transported in psych unit to ADP- 53

Transported in psych unit to ED- 260

Psych Transports by ambulance to ED 79

Calls medical and not psych in nature 88