Program joins physical, behavioral healthcare
Initiative focuses on mentally ill patients
UPMC Insurance Division’s Connected Care, a program that links behavioral health providers and medical providers, has reduced the use of behavioral and physical health services by participants in the program.
"We’ve seen a significant reduction in hospital admissions and emergency department visits among members in Connected Care," says James Schuster, MD, chief medical officer for Community Care Behavioral Health Organization, which partnered in this effort with UPMC Health Plan and the Allegheny County Office of Mental Health.
The program provides coordination of mental health and physical health benefits for members of UPMC for You, a Medicaid managed care plan as well as Community Care Behavioral Health for its behavioral health services. Community Care manages behavioral health services for recipients of Pennsylvania’s Medical Assistance program in 39 counties.
Connected Care is an effort to better coordinate care for individuals with serious mental illness by linking health plans, personal care physicians, and behavioral health providers in outpatient, inpatient, and emergency department settings, Schuster says. The program aims to improve the health of people with serious mental illness and enhance the patient experience of care by coordinating both physical and mental health services as well as minimizing the cost of care for the population.
"Many individuals with mental illness have wellness and physical health issues as well," Schuster says. The majority of people with serious mental illness smoke or are significantly overweight, and many have chronic conditions such as diabetes, heart disease, and respiratory problems. Even without health problems, their behavior often places them at risk," Schuster says.
When it created Connected Care, UPMC merged data from care management systems at UPMC for You and Community Care Behavioral Health to create a database that both physical health and behavioral health care managers use to share information about patients. The database helps staff identify what providers each member is seeing, what case manager from each component is coordinating care, and any barriers to receiving care that have been identified. A multidisciplinary team from both Community Care and UPMC for You worked together to design the program.
"Connected Care allows us to share information about acute services with providers. If members have a hospital admission, we notify behavioral health providers who use the information as an opportunity to reconnect with the patient," Schuster says.
The care managers from both organizations were trained to function as wellness and health coaches as well as learning how care coordination works in both organizations.
The program has developed patient registries that list members with gaps in care for preventive services or chronic conditions, cuing the case managers to intervene. The care managers notify primary care and behavioral health providers, including community-based case managers, when patients are admitted to the hospital or visit the emergency department and when there are gaps in refilling antipsychotics and receiving recommended lab tests and other care.
As members are identified, a multidisciplinary team from both organizations discusses the case and chooses a lead case manager, based on the member’s needs and existing relationships. The multidisciplinary team works together to develop individual integrated care plans for each member in the program and meets periodically to discuss specific patients with complex needs and brainstorm on ways to help them follow their treatment plan. The lead care managers contact patients by telephone and make sure they understand their medication regimen and work with them on following their treatment plans. The team contacts each individual’s mental health and physical health provider, informs the provider of the treatment plan, and talks with a therapist or a nurse about concerns for each individual patient.
When patients are admitted to the hospital, the program care manager assists with developing the discharge plan and follows up to ensure that patients receive a post-discharge visit with an appropriate physician and understand their discharge plan and how to take their medication. In addition, the care coordinators share information with primary care providers about the patients’ behavioral health interventions and alert mental health providers when patients have a medical intervention.
"The care managers do a lot of work and ongoing communication to engage community-based mental health providers and care managers as well as working to support the primary care physicians in managing the physical health of the patients. In the past, communication between providers was not as predictable or regular. We created a structured process to make sure that physicians and behavioral health providers are aware of what’s going on with patients in regards to both their physical and behavioral health issues," Schuster says. n
Team reduces ED wait times, improves safety
Collaboration nurtures quality improvement
The fast pace of a busy ED can make it difficult to focus in on processes that could be improved, but leadership and commitment can move the needle in the right direction as long as emergency personnel understand why change is important. That, at least, is what Erin Muck, RN, the ED manager and trauma coordinator at Avera Marshall Regional Medical Center, a 25-bed hospital in Marshall, MN, has discovered. The ED treats about 7,200 patients annually, and 100 patients per month are admitted to the hospital from the ED.
When the ED at Avera Marshall began participating in a project aimed at improving throughput times toward the end of 2011, Muck utilized a collaborative process to identify steps that could be improved. Muck asked one of the ED’s four physicians to participate in the effort by attending a monthly meeting in which ideas would be solicited and discussed. She also invited nurses to participate, and she brought in representatives from the lab and radiology departments as needed. Two representatives from the hospital’s quality department participated in the meetings as well.
To make it convenient for the physician to participate, Muck says she always scheduled the meetings during the morning hours when the ED is typically not as busy, generally around 9 a.m. The discussions typically lasted for 30-60 minutes, she explains.
Use data to drive improvement
Over a period of several months, the so-called "quick-hits" meetings produced a number of ideas to shorten wait times for patients while also improving safety. One of the biggest improvements that resulted from the process was a reduction of 12 minutes in the ED’s average decision-to-admit time, bringing this metric from 44 minutes down to 32 minutes. "It was hard to address the decision-to-admit times because a lot of people don’t document them," says Muck. "It took us a good six months just to get that piece of it done."
The "quick hits" team theorized that the admission process could be expedited if the charge nurses were notified earlier on that a patient was likely to be admitted. "That way they could be thinking about who they are going to assign the patient to, what room they are going to open up, and those kinds of things," says Muck. Under this type of arrangement, charge nurses would be able to give the nurses on the inpatient floors a heads-up when they are likely to receive a patient. "It would just give them the time to wrap up whatever they are doing so that they are prepared for an admission," says Muck. Also, the charge nurses would be mentally prepared for a phone call when the decision to admit is made by the physician, she says.
One other reason why Muck felt the approach would work well is because she has a very experienced group of nurses manning the ED. "The nursing staff here average about 24 years of service, so they are very well versed in working the ED and estimating [which patients are likely to be admitted]," she explains. "They do a pretty nice job."
However, when the approach was first implemented, there was snag. "Most of the charge nurses were awesome about this," says Muck, but there was one charge nurse who was not acting on the early information. Consequently, Muck shared a report with the charge nurses showing the decision-to-admit times per charge nurse. "Then she stepped up her game," says Muck.
To sustain the improvement in decision-to-admit times, Muck acknowledges that she needs to keep her eye on it. "If I am not watching that constantly and putting the data out there for [the staff to see], then it is out of sight, out of mind, so then they aren’t doing quite as well," she says.
A similar approach worked well in getting the physicians to pay attention to their throughput times. "Every month I would have a printout of our general throughput times, and then I would have it per physician," says Muck. "Occasionally, I still run those reports. We have some locum physicians [who work in the ED now], so I want to keep track of them and how their throughput times compare with our own physicians. It is a little friendly competition."
Other ideas that came out of the "quick hits" process include the establishment of a goal for completing the triage process by the time a patient has been in the ED for 10 minutes. Also, blood is now routinely drawn during triage for patients who present with an issue that will likely require blood work, such as patients presenting with abdominal pain, explains Muck. "We figured out how to do triage quicker and better, and these were ideas that we got from the nursing staff, physicians, and sometimes lab or X-ray," she says.
While some organizations might struggle to prevent this type of team-driven process from turning into a blame game, Muck says hospital administrators have nurtured a culture in which it is not OK to get defensive or angry when discussing problems. "We don’t have that problem here. It is always good to get advice," she says. "The managers work well together and we are always open for suggestions. If my suggestion doesn’t work, then they will suggest something different that does."
Muck acknowledges that it can be more difficult to get physicians on board with any type of change. The key, she says, is making sure they understand what the benefits will be of a change in process. She adds that a team-driven approach can facilitate this type of exchange. "In order to problem solve, it is good to have the people involved because you can have better buy-in regarding how to fix things," she says.
While the formal monthly "quick hits" meetings no longer take place, Muck explains that she regularly uses the approach for quality improvement. For example, she is now engaged in an effort to identify ways to improve trauma care. "We have a trauma surgeon involved, trauma physicians, and sometimes orthopedics as well," she says. "Who we invite to the meetings just depends on what issue we are addressing."
Erin Muck, RN, ED Manager and Trauma Coordinator, Avera Marshall Regional Medical Center, Marshall, MN.