Improving Healthcare Quality: Advanced Clinic Access in Mental Health

Mary Schohn, Ph.D.

April 24, 2004

Background

Quality of healthcare is determined by the design of the healthcare system (Berwick, 2003).

Three major gaps in the current delivery of healthcare are: (IOM, 2001) Overuse of procedures that do not help people get

better Under use of procedures that can help Misuse or errors

Roadmap to improvement

Identify gaps between current performance and desired performance

Seek new designs Involve everyone (Berwick, 2003)

VHA/IHI Collaborative

Started in 1999 Goals

Reducing Delays and Wait Times by 50% in six pilot clinics

Redesign clinic scheduling based on model of “open access”

Spread across all of VHA

Improvement in Average Next Available Appointment

Reduction in Wait Times While Patients Increase

Mental Health and ACA

Director’s Performance Measure FY04 Added three Mental Health Clinics (502, 509, 510) to the ACA

Initiative for reducing waiting times Director’s Performance Monitors FY04

Number of clinics with wait time greater than 45 days includes 502,513,531,540 and 547

Number of patients waiting more than 30 days beyond the their desired appointment date.

Percentage of appointments scheduled as “next available” compared to the national average for the MH Performance clinics.

No show rates

Current status

Stopcode

Next Available Wait

# of New Appointments

Total New Appoint Wait

Percent of Next Avialable Seen in 30 days

502 22.4 39,436 30.7 78.38%509 24.1 11,966 34.4 76.26%510 18.3 8,267 21.5 86.78%513 8.4 7,778 12 94.29%516 3.5 493 37.6 97.39%525 34.8 75 13.4 34.55%530 239.7 6 0 0.00%531 20.3 5,437 29.6 80.56%538 25.2 2,139 42.4 82.08%540 18.4 4,434 30.2 82.64%547 2.9 2,846 8.3 99.12%561 5.8 2,270 37.5 98.28%562 23.9 844 46.2 80.23%576 26.3 1,088 47.8 73.93%

Common Strategies Used in Mental Health ACA in VA Match Supply and Demand

Measure supply and Demand Define supply

Sum of clinic slots Based on FTEE assigned to clinic Panel sizes

Define demand Sum of consults, walk-ins, calls for appointments, rebooks

Common Strategies used in Mental Health ACA in VA Match Supply and Demand

Reduce appointment types Review appointment types to see if efficiencies can

be gained by eliminating appointment types; eg. Reduce/eliminate intake appointments; provider who does initial assessment provides the ongoing care; 30 minute appointments only; triage appointment completes the intake appointment.

Common Strategies used in Mental Health ACA in VA Match Supply and Demand

Plan for contingencies Be aware of seasonal variation in demand and

supply Plan for variations; develop time off policies to

ensure coverage; cross coverage arrangements

Common Strategies Used in Mental Health ACA in VA Shape the Demand

Work Down the Backlog Hire temporary staff; detail staff, use OT Review provider schedules Reduce other demands on providers time

temporarily

Common Strategies used in Mental Health ACA in VA Shape the Demand

Reduce the Demand Reduce return rate visits “what’s the value of the next appointment?” Increase graduation rates Develop specialty agreements Reduce no-show rate Reduce automatic “rebooks” for no-shows Increase group visits Make the first visit count

Common Strategies Used in Mental Health ACA in VA Redesign system to increase supply

Manage the constraint Figure out the bottleneck in the process eg. Lack of

intake slots; drop-ins; telephone calls; documentation time

Common Strategies Used in Mental Health ACA in VA Redesign System to Increase Supply

Optimize the care team Review team functions and assignments – don’t

have MDs doing work that clerks or nursing staff can do eg. AIMS, care coordination, scheduling; use of dictation

Redistribute case load to mid-levels

Common Strategies Used in Mental Health ACA in VA Redesign System to increase supply

Predict and anticipate patient/system needs at time of appointment

Max packing- ensure clinical reminders are done at time of visit

Depression follow-up preset orders

Common Strategies Used in Mental Health ACA in VA Redesign System to Increase Supply

Synchronize patient, provider and information Improve consult requests

Optimize rooms and equipment eg. Telepsychiatry in CBOCs

Role for Psychology Leaders

Make it a priority Develop Teams Review actions

Aims and goals Monthly progress report Plans for testing and implementing changes Provide for spread activities and opportunities Identify opinion leaders

Role for Psychology leaders

Empower and Support Champions Promote the project Publicize team achievements Present outcomes at regional/national meetings Convert resistance Research outcomes Become a Clinical Coach

Resources

ACA Liaison to MHSHG Robert Gresen, Ph.D.

MH Liasion to ACA Steering Committee Mary Schohn, Ph.D.

ACA website http://vaww.vsscportal.med.va.gov/aca/

ACA MH Monthly Conference Calls

Resources

VISN MH POC MH ACA Mail group MH ACA Satellite Videoconference

August, 2004