Acute Behavioral Health CareImprovement Project

ASHNHA Legislative Fly-inFebruary 2019

• Understanding the Problem– Why now?

• ASHNHA Behavioral Health Workgroup– How should we address the problem?

• Workgroup Recommendations– What should we do?

Acute Behavioral Health CareImprovement Project

National Consequences of De-Institutionalization

Reproduced from Cravez, “Alaska’s Lack of Psychiatric Beds and Consequences,” Alaska Justice Forum34:1 (Summer 2017), updated May 21, 2018. Published by University of Alaska Anchorage Justice Center.

A Confluence of Events

Increasingnumbers of behavioral health patients in hospital Emergency Departments

Decreases in inpatient capacity

Increased demand for

services

Percentage of behavioral health ED stays lasting 12 hours or more

Source: Alaska Health Analytics and Vital Records, Health Facilities Data Reporting Program

58%

31%

5% 3% 2% 1% 0.2% 1%

42%38%

7% 4% 4% 2% 2% 3%

44%

30%

5% 3% 3% 2% 2%

11%

0%

10%

20%

30%

40%

50%

60%

70%

12-23 24-35 36-47 48-59 60-71 72-83 86-95 96+

HOURS2016 2017 2018 Q1-Q2

• ASHNHA, supported by funding from The Alaska Mental Health Trust Authority initiated the Behavioral Health Care Improvement project.

• Launched in August to improve care for behavioral health patients presenting at emergency departments:

1. Develop solutions to re-align the system2. Improve care of behavioral health patients3. Identify strategies to intervene before crisis period

• ASHNHA contracted with Agnew::Beck to support the stakeholder process, research possible solutions, and document the group’s recommendations.

• Additional funding requested from the Hospital Preparedness Program to support improved care in ED for BH patients.

Acute Behavioral Health Care Improvement Project

Opportunities for Prevention at Each Step in the ProcessFrom Crisis to Stabilization to Follow-up Care

Source: Laderman M, Dasgupta A, Henderson R, Waghray A, Bolender T, Schall M. Integrating Behavioral Health in the Emergency Department and Upstream. IHI Innovation Report. Boston, Massachusetts: Institute for Healthcare Improvement; 2018.

What are the Critical Gaps in Alaska’s System?

Psychiatric CapacityEvaluation + consultation

about medication and treatment in the ED

Standard Processes + Protocols in the ED

Well-defined processes to care for psychiatric patients

ED Staff CapacityTeam trained and ready to care for psychiatric patients

ED Coordination with Community Providers

Next-day follow up appointments, share care plans

Short-Term Treatment Beds

Inpatient capacity for short-term psychiatric treatment

Long-Term Treatment Beds

Inpatient capacity for long-term psychiatric treatment

Top Priorities: Emergency Departments

1. Improve process for post-discharge follow-up 2. Increase designated observation units in EDs and

inpatient3. Guide implementation of Project BETA best practices 4. Hire psychiatric nurses and/or mental health aides in

EDs5. Initiate Medication Assisted Treatment in EDs6. Implement brief intervention protocols (SBIRT) in EDs7. Expand psychiatric ED model in Anchorage and Mat-

Su

Top Priorities: Hospital Inpatient Units1. Identify a reliable Medicaid reimbursement methodology for

hospitals to increase inpatient capacity for short-term treatment.

2. Advocate for a stable policy and reimbursement environment.3. Develop a statewide triage system for transfers of civil

involuntary commitments to API to ensure highest acuity prioritized for transfer.

4. Staff hospitals with case managers to coordinate, help access resources.

5. Evaluate and potentially revise the Mental Health Treatment Assistance Program to optimize resources for treatment beds and secure transport.

Top Priorities: API

1. Advocate for API to provide both acute and longer-term treatment in a safe and secure setting.

2. Increase average length of stay and reduce recidivism to API.

Top Priorities: Across the Continuum1. Develop a shared tele-psychiatry contract among

hospitals for psychiatric consults in ED and inpatient units. Remove barriers to licensing for providers.

2. Implement use of EDie across hospital, behavioral health and primary care providers, starting with addressing API’s barriers to using EDie.

3. Evaluate the need for changes to Alaska statutes regarding civil commitment, length of commitment, and use of involuntary commitment process to facilitate a patient’s access to psychiatric treatment.

Now What? • Great findings! Now, what about resources?

Use existing resources more

effectively

Find new revenues

Use Existing Resources More Effectively

Behavior: psychiatric diagnosis API

Align the Incentives in Your ED

0

100

200

300

400 Average Annual Transfers to API (FY17 – 18)

• API transfer:– Safe– Cost effective (shifts)– Reduces workload

• GOAL– Create financial incentive for relational-based

treatment, not transfer– Create expectations by asking questions

Align the Incentives in Your ED

• Cyclical volumes – annoying, then incapacitating, then goes away (temporarily)

• Two potential areas to pool resources– Post-discharge follow-up – On-demand Telepsych/MAT

Pooling Resources

Improve Skills / CapacityOverview of Project BETA: Best practices in Evaluation and Treatment of AgitationGarland H Holloman, Jr, MD, PhD* and Scott L Zeller, MD†

• Agitation is a leading cause of hospital staff injuries and can cause untold physical and psychological suffering for patients and all those nearby.2–4

• Yet, despite the pervasiveness of agitation, there is surprising inconsistency in treatment approaches, which can vary widely by region and institution.

• ….far too many agencies still treat all episodes of agitation in a fashion that might best be described as “restrain and sedate.”

• Best practices in Evaluation and Treatment of Agitation (BETA) patients will come

• Wrote five articles1. Medical evaluation and triage of the agitated patient2. Psychiatric evaluation of the agitated patient3. Verbal de-escalation of the agitated patient4. Psychopharmacologic approaches to agitation5. Use and avoidance of seclusion and restraint

Project BETA

Now What? • Great findings! Now, what about resources?

Use existing resources more

effectively

Find new revenues

• Where is the money for treating this population?

• Importance of braided funding– Psychiatric Emergency Services (grant dollars)– IP coverage, consider small subsidy (think hospitalists)– Professional fees

New Revenues Needed

Grant

Pro FeesSubsidy

• Facility Fee: OBS status for up to 120 hours• Pro Fees

New Revenues

Licensed Psychologist or Licensed Psychiatrist

CPT 90839 or 90840; Psychotherapy for Patients in Crisis

First 60 minutes = $216.81; add 30 minutes = $103.73

Max of 3 hours per day, or $631.73

Seeking written confirmation form State (Medicaid)

• Use braided funding model

• Put sufficient package together– Consider 7 am – 7 pm coverage model– Make financial package attractive– Consider contracting the service out, with requirements

• Start treating patients, rather than triaging and transferring them!

New Revenues: Keys To Success

Thank You / Questions

Matt Dammeyer, Ph.D.Cell: 907-398-5320Email: mattdammeyer@gmail.com

Elizabeth King, MPHOffice: 907-270-6447Email: elizabeth@ashnha.com