Jim Taliaferro CMHC Admission & Evaluation Services Unit

Transforming the Concept,Process & Environment of

Transforming the Concept,Process & Environment of

Introduction

The Jim Taliaferro Community Mental Health Center Triage Unit was established in early 1990 and is now referred to locally as the “Admission and Evaluations Services Unit”. This unit provides consumer screening for mental health issues, substance abuse services, and provides timely crisis interventions for all Oklahomans in our nine county catchment area in Southwest Oklahoma. The mission of Admission Services is to complete evaluations for all consumers presenting to JTCMHC to determine a diagnoses and assess the type of service that can be provided by our facility to the consumer.

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Our Coverage Area

The Challenge

During the 2009 fiscal year, a severe shortage of physicians made it necessary to admit all consumers presenting to Inpatient under ED status after 5:00 pm daily, as there was no physician available to evaluate them until the following morning. This, in turn, produced an unacceptable number of admissions with stays of less than 24 hours, bringing down the average length of stay from 4-5 days to just 2 days. Because the timeframe for completing all assessments and the interdisciplinary treatment plan is determined by the average length of stay, when we were surveyed in 2008 by Center for Medicare and Medicaid Services (CMS) we were required by them to change our policy and to complete all assessments and treatment plans in just 48 hours instead of the usual 72. This change made it necessary to have social workers on site 7 days a week, and even so, the 48 hour deadline was not consistently being met, placing our CMS certification in jeopardy.

The initial purpose of this project was to eliminate the need to admit consumers who did not meet ED criteria and hopefully to return to our pre-crisis average length of stay.

Cost OverrunsBecause of

Bad EDAdmits

$ 1,000,000In Funding in

Jeopardy No Physician

Coverage

The TeamA team comprised of directors and coordinators was designated by our Facility Executive Director to address these issues and provide an economical solution.

Jim Regan Executive Director

Mike Strickland, MD Clinical Director

Judy Wallace, Process Improvement

Victor Wilkerson Inpatient Director

Ellie Cruz, RN Director of Nursing

Jill Melrose Evaluations Unit Coordinator

Randy Kauk Senior Evaluation Specialist

Our Goals

A team comprised of directors and coordinators was designated by the Facility Executive Director to address these issues and provide an economical solution with the following goals:

Develop call-coverage strategies and closer alignment with key physicians

Create a staffing plan that reduces costs and increases coverage during peak hours.

Improve the Emergency Detention Admission Process to provide better integration with Law Enforcement Agencies

Reduce crowding, wait times, and the number of patients who leave without being seen

Expand and remodel the Evaluation Unit

Provide better patient and staff safety while increasing overall program satisfaction

Provide comfort rooms to consumers and law enforcement personnel to make any wait times more tolerable

PDSA3 Model

Methods

To accomplish the objectives the Facility Executive Director put before the team the PDSA3 (Plan, Do, Study, Act) model was utilized. Admission and length of stay data from the inpatient unit was collected and compiled for a 6 month time frame to establish trends and peak admission times for each day of the week. It became immediately apparent that by eliminating admissions released immediately after evaluation, the average length of stay would return to pre-crisis levels. It was also determined that by locally adjusting staffing level to the unit would save our facility approximately $230,000 in payroll. Additional cost savings would also be realized from the decrease in frivolous admissions thus reducing overall operational cost in our inpatient unit.

Total CMSCompliance!

$230k+ inPayroll Saved!

ReducedOperating

Cost

Plan

Do

Study

ACT

Methods

Plan• Decrease bad

admissions

• Increase ALOS

• Use current professional staff without hiring

Do• Expand and remodel

the Evaluation Services area

• Restructure Evaluation Services

• Reallocate existing LMHP staff to provide extended hours of service from 5 PM to midnight

• Provide comfort rooms for waiting consumers and Law Enforcement Officers

Study• ALOS before and after

implementation

• Cost of implementation vs. cost of additional MD/LMHP personnel

Act• Implement 24 hour

services

• Implement remote tele-presence evaluations

The Solution

THE NEWJIM TALIAFERRO CMHC

ADMISSION & EVALUATION SERVICES

UNIT

How it works

JTCMHC recognizes the importance of mutual respect and cooperation between our staff and law enforcement, and we make every effort to extend our “warm and welcoming” attitude towards our law enforcement officers as well as our consumers. They are made to feel welcome from the moment they drive into our parking lot with their own designated parking spaces “front and center”.

The redesign of our Evaluation Services Unit has resulted in a new entrance for law enforcement. The old design made it necessary for the officers to enter with consumers through a side door which opened directly onto the Inpatient Unit.

1. Consumer is transported to our facility.

How it works

Adding to the sense of home-like tranquility, at the entrance to the Evaluations Unit is a bright and cheery kitchen for preparing coffee, beverages and nourishments for our guests.

Proceeding down the hallway just beyond the kitchen are locked cubbies where law enforcement officers can store their guns. Just around the corner and next to the water fountain is an on-site bathroom which eliminates any need for consumers awaiting evaluation to have to leave the Unit until such time as they are admitted or released.

How it works

Our new “comfort room” is a welcoming safe haven for consumers as they await evaluation. The pull-out sleeper chairs are stocked with pillows and blankets under the seats and the adjustable lighting creates a warm and relaxing oasis.

(Simulated consumer)

On the new Unit, confidentiality is maintained and the consumer does not enter the Inpatient Unit unless admitted.

2. They are welcomed to our newly remodeled Admissions & Evaluations Unit

How it works

Here again, we are pampering our law enforcement officers in their own comfort room as they wait for consumers to be evaluated. The room is right next to the consumer’s comfort room and will soon have a one-way observation window on left wall so that the officers can observe their charges. Refreshments are available, as well as reading materials.

Law Enforcement &Department of Corrections

areWELCOME

How it works

This is one of three triage offices where our evaluations take place and one of our wonderful triage staff. They all take pride in making their offices warm and inviting.

(Simulated consumer)

3. Consumer is evaluated, and if criteria is met, admitted by friendly and concerned staff.

Results

Before After0

50

100

150

200

250

300

350

309 160

The number of Inpatient stays less than 24 hours from May 2008 to April 2009

48%

• Stays of < 24 hours cut in half

• Increased ALOS from 2-3 days to 4-5 days

• Decreased wait time for evaluations

• Increased consumer satisfaction

• Improved relations with law enforcement

• Improved staff morale

• 27% decrease in < 30 day readmissions

More M.H. BedsAvailable

DecreasedE.R. & Jail

For Consumers

EnhancedQuality of

Care

$230k+ inPayroll Saved!

No AdverseTreatment

Costs and Returns

Remodeling our Evaluation Unit to provide a warm and inviting atmosphere to both consumers and law enforcement -

$10,000

Payroll saved because we reallocated current staff

instead of new hiring - $233,840

Transportation and Operating costs deferred because of the prevention of frivolous E.D.

Admissions - $228,000

One Oklahoman not receiving an unnecessary mental health record -

PRICELESS

On 8/10/2009 we received a call from Jackson County hospital afternormal business hours for an evaluation of a 55-year-old woman who had been admitted for uncontrollable blood pressure and low oxygen levels. She had to be constantly monitored at the hospital because of her unstable medical condition. She was complaining of voices telling her to kill herself. Over the course of her hospital stay, her mental state had cleared, but her doctor would not release her without a psychological evaluation. The Evaluation Unit decided to provide the evaluation at our satellite office in Altus with a Licensed Mental Health Professional in Lawton via video conference. This would save the fragile lady with oxygen tanks from making a three hour trip to Lawton

in the custody of a police officer. (Law Enforcement was also interested in this solution as it would be saving them time and money.) The woman was evaluated via video conference and was found to no longer have hallucinations or any suicidal intent, nor did she meet criteria for an inpatient admission to our facility. This was our center’s first Psychological Evaluation via video conference. Both the police and the hospital in Altus have asked for a meeting on the new possibility of remote evaluations because of the convenience, cost savings, and reduction in further trauma to their consumers.

Success Story

Hope

Where to from here?

• Expand Evaluations Unit coverage from midnight to 8 am1

• Implement evaluations via electronic video conferencing between local Emergency Rooms, Law Enforcement Agencies, and Court Houses, and Dept. of Corrections

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