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DevelopingaHospital-BasedPerformanceImprovementProjecttoReduce30-Day
PsychiatricReadmissionsatUTHealthHarrisCountyPsychiatricCenter
JaneHamilton,Ph.D.,M.P.H.,L.C.S.W.,AssistantProfessorOliviaMoffitt,M.D.,PsychiatryResident
McGovernMedicalSchool,DepartmentofPsychiatryandBehavioralSciences
ImpactingPopulationHealth• TheUniversityofTexas,HarrisCountyPsychiatricCenter(HCPC)isimplementingapopulationhealthapproach,interveningwithpatientsbothasindividualsandasmembersofapopulationwithseriousmentalillness.
• TheinitiativeincorporatespreviousresearchconductedatHCPCthatsuggestssomepopulationgroupsaremorevulnerabletoaparticularhealthoutcomethanothers.
• Usingthisapproach,HCPCisabletoidentifythehealthandsocialneedsofitspatientpopulationanddeterminehowbesttopreventormeetthoseneeds.
WhyExamine30-DayPsychiatricReadmissions?
• Healthcarereformestablishedthegoalofreducing30-dayreadmissionsacrossmedicalconditions.
• Increasedinterestin30-daypsychiatricreadmissionratesasqualityindicators.
• Internationallyacceptedindicatorofthequalityofinpatientcareaswellasthetransitiontocommunity-basedcareafterdischarge.
UTHealthHarrisCountyPsychiatricCenter(HCPC)• Academicsafety-netpsychiatrichospitalinHouston,Texas.• Approximately9,000 children,adolescents,andadultsareservedperyear.
• 276 beds,10 psychiatricunits,and20 attendingpsychiatrists.
• In1990,apatient’saveragelengthofstaywas27days.
• Today,ouraveragelengthofstayis7days.
• Manypatientsareinvoluntarilyadmittedthroughacourt-orderedcommitmentprocess.
HCPCPatientCharacteristics
PatientCharacteristic Percentage
Male 61%
Non-Hispanic White 41%
African American 41%
Hispanic 17%
Schizophrenia 28%
MajorDepression 28%
Bipolar Disorder 38%
Uninsured 85%
DischargedintoHomeless Shelters 33%
StatementoftheReadmissionsProblemChronicrecidivismandrapidreadmissionsareagrowingconcernatHCPCduetoincreasedcostsandlessthanoptimaloutcomes.
2016ReadmissionsData
AdmissionType HCPC BedDays Costs($530/BedDay)
30-DayReadmission 8,925 $4,730,250Super-Utilizers
(4+AdmissionsperYear)8,362 $4,431,860
Note:195 super-utilizerpatientsaccountedfor971 admissionsaccountingfor11% ofall2016admissions.
ReadmissionsResearchatHCPCStudy1: FactorsDifferentiallyAssociatedwithEarlyReadmissionataUniversityTeachingPsychiatricHospital.(HamiltonJ.E.etal.JournalofEvaluationinClinicalPractice.2015).
Study2: PredictorsofPsychiatricReadmissionamongPatientswithBipolarDisorderatanAcademicSafety-NetHospital.(HamiltonJ.E.etal.AustralianandNewZealandJournalofPsychiatry.2016).
Study3: Post-DischargeEngagementwithOutpatientMentalHealthServicesamongFemalePsychiatricPatientsReadmittedwithin30DaysofDischargeaMixed-MethodsAnalysis.(HamiltonJ.E.etal.InPreparation).
1st Study:FactorsDifferentiallyAssociatedwithEarlyReadmissionatHCPC
• Qualityimprovementinterviews(n=588)wereconductedwithpatientsreadmittingwithin30daysofHCPCdischargefromJanuary2001toNovember2010.
• Interviewdataweremergedwithelectronicmedicalrecorddata.
• Statisticalmodelingwasconductedtoidentifypredictorsofearlierreadmission:post-dischargedays1– 7anddays8– 14comparedto15– 30daysafterdischarge.
30-DayReadmissionPatientInterviewQuestionsMaritalstatus?
Employmentstatus?
Yearsofeducation?
Arresthistory?
Voluntary/Involuntarystatus?
Sincethehospitalization,hasthepatientbeenemployed?
Doespatienthavefinancialsupport?
Wheredidthepatientliveafterthelasthospitalization?
Whatisthepatient’sbeliefastowhys/hereturnedsoquickly?
Overallhelpfulnessofthelasthospitalstay?
Adherencewithpsychiatricmedication?
Whatispatient’soverallexperiencewithmedicationeffectiveness?
Whatispatient’soverallexperiencewithmedicationsideeffects?
Patient’saftercareagencyreferral?
Patient’sattendanceattheaftercareagency?
SignificantPredictorswithin7Days AdjustedOddsRatio
ElevatedMentalhealthSymptoms(BriefPsychiatricRatingScale)• Grandiosity• Suspiciousness
1.51.4
Inconsistent FinancialSupport 4.0
Readmitted before1st scheduledaftercareappointment
10.2
Missedfirstaftercareappointment 2.4
SignificantPredictors8- 14Days
HighSchoolDegree 1.9
Readmitted before1st scheduledaftercareappointment
2.5
PredictorsofPsychiatricReadmissionamongPatientswithBipolarDisorder
• StudyexaminedpredictorsofHCPCreadmissionwithin30days,90daysand1yearofdischarge.
• ConceptualmodeladaptedfromAndersen’sBehavioralModelofHealthServiceUse.
• Statisticalmodelingwasconductedinasampleof2443adultpatientswithbipolardisorderadmittedtoHCPCfromJanuarythroughDecember2013toexaminesignificantpredictorsofreadmission.
Andersen’sBehavioralModelofHealthServiceUse
Groupsfactorsassociatedwithhealthserviceutilizationintothreecategories:
• Predisposing(characteristicsoftheindividualincludingage,gender,race,maritalstatus)
• Enabling (systemorstructuralfactorsthatmakehealthserviceresourcesavailabletotheindividual)
• Need(severityofillness/clinicalfactors)
AndersenR,NewmanJF.SocietalandindividualdeterminantsofmedicalcareutilizationintheUnitedStates.MilbankMemorialFundQuarterly.1973;51,95–124.
AndersenRM.Revisitingthebehavioralmodelandaccesstomedicalcare:Doesitmatter?JournalofHealthandSocialBehavior.1995;36,1–10.
HCPCPatientswithBipolarDisorder
PredisposingFactors(Age,Gender,Race/Ethnicity,
MaritalStatus)
EnablingFactors(InsuranceStatus,Homelessness,PriorUtilization,Involuntary
Status)
NeedFactors(BipolarDisorderType,CurrentManicEpisode,GAFScore)
HCPCPsychiatricReadmission
ConceptualModel:Andersen’sBehavioralModelofHealthServiceUse
StudyResultsAcrossalltimeperiods,increasedreadmissionriskassociatedwith:
• Beinguninsured• 3ormorepsychiatrichospitalizations• AlowerGlobalAssessmentofFunctioning(GAF)score
Within30and90daysofdischarge,increasedreadmissionriskassociatedwithpatienthomelessness.
Within1yearofdischarge,increasedreadmissionriskassociatedwithmalegender.
SpecialPopulations:Examining30-DayPsychiatricReadmissionsamongWomenwithSeriousMentalIllness
StudyAims:Describefactorsinfluencing30-daypsychiatricreadmissionsamongwomenusingaSocialDeterminantsofHealthframework.
Methods:HCPCsocialworkersconducted60semi-structuredinterviewswithadultfemale30-dayreadmittedpatientsin2016.Medicalchartreviewswereconductedtosupplementtheinterviewdata.Interviewresultsaresharedwiththenewtreatmentteamtoinformcurrenttreatmentplanning.
TranslatingResearchtoPracticeGoals:Developatailoredinterventiontoimproveengagementwithoutpatientservicesandreducepsychiatricreadmissionsamongadultfemalepatients.
PatientInterviewForm:30-DayPsychiatricReadmissions
MedicalRecordNumber:____________NumberofDaysbetweenHospitalizations:___________Involuntary:Y□ N□ Homeless:Y□ N□
Whatispatient’sbeliefastowhys/hereturnedsoquicklytothehospital?(Checkallthatapply)□ Patientwasn’treadytoleaveduringprevioushospitalization□ Medicationproblems□ Livingsituationafterdischargewasstressful(environmentalstressors)□ Other
Y□ N□ Didpatientattendanyaftercareappointments?(Ifno,pleaseanswerthenextquestion).
Patient’sdescriptionwhys/hedidnotattendaftercareappointments(pleasedescribeinpatient’sownwordsusingquotationmarks):
Ifpatientdidattendaftercare(pleasedescribeinpatient’sownwordswhatfactorshelpedwithsuccessfulengagement):
Y□ N□ Wastherepost-dischargesubstanceabuse?
Patient’sdescriptionofwhatledtothisreadmission(pleasedescribeinpatient’sownwordsusingquotationmarks):
PreviousSocialServicesclinician’sperceptionoffactorsleadingtothisreadmission(pleasedescribeinsocialworker’sownwordsusingquotationmarks):
30-dayReadmissionInterviewResults
Only12% ofadultfemalepatientsinterviewedreportedattendinganaftercareappointmentpriortoreadmission.
43% reportedusingsubstancesafterdischarge.
PatientReportedBeliefsaboutReasonsforReadmission37%reportedhavingmedicationproblemsafterdischarge.40%reportedlivinginastressfulenvironmentafterdischarge.
Chartreviewsrevealedthemajorityofpatientsinterviewedhad4+HCPCadmissionsandwereunemployed,homeless,uninsured,andinvoluntarilyreadmitted.
FocusGroupswithHCPCPatientstoTailorReadmissionsReductionInterventions
In2016,weconductedtwofocusgroupsontheHCPCSchizophreniaUnittoobtainpatient-reportedinformationon:• Interventionneedsandpreferences.• Barriersandfacilitatorstopost-dischargeengagementinoutpatientservices.
ThemesEmergingfromFocusGroupData
• Patientsexhibitedlowlevelsofhealthliteracyandreportedlackingunderstandingoftheirmentalillnessesanddischargeplans.
• Patientsreporteddifficultiesaccessingpsychiatricmedicationsandattendingscheduledappointments.
TranslatingResearchtoPracticeOurresearchenabledustoidentifypriorityareasforimplementingstrategiestoreduce30-dayreadmissionsandtointervenewithsuper-utilizers.
• MedicationAdherence• EngagementinPost-DischargeOutpatientServices• SubstanceUse• HousingInstability/Homelessness
Basedonthesepriorityareas,weareleveragingexistinghospitalresourcestoimplementevidence-basedinterventionsandarecreatingcommunitypartnershipstoreducereadmissions.
LeveragingtheHCPCElectronicHealthRecord(EHR)toIdentifyHigh-RiskPatientsthroughRiskStratificationAnalertsystemisbeingimplementedintheEHRtotargetthefollowingpatients:• Patientsatriskfor30-dayreadmissions• Super-utilizerpatients(4+HCPCadmissionsin1Year)• Homelesspatients
Weconductedasystematicreviewofthepsychiatricreadmissionsliteraturetoidentifyreadmissionsriskfactors(n=18studies).
7 studiesfoundapositiverelationshipbetweenagreaternumberofpreviouspsychiatrichospitalizationsandreadmissionwithin30daysofdischarge.Applebyetal.,1993;Swett,1995;NicolsonandFeinstein,1996;Monnelly,1997;Zilber,Hornik-Lurie,Lerner,2011;Kreys etal.2013;Hamiltonetal.,2015.
PriorityArea Intervention
MedicationAdherenceSharedDecisionMakingTeach-BackMedication Reconciliation
PatientEngagementMotivationalInterviewingIntensiveCaseReviews
SubstanceUse
Inpatient SubstanceUseGroupsPatient andFamilyPsychoeducationReferralsto evidence-basedservices
HomelessnessSupported HousingReferralsto evidence-basedservices
InterventionMappingHesselinketal.BMCHealthServicesResearch2014
SharedDecisionMaking(SDM)ThePinnacleofPatient-CenteredCare
Aprovider’sroleinSDMisto:• Educatepatientsaboutallavailabletreatments.• Acknowledgeandhelpclarifypatientpreferencesandvalues.• Empowerpatientstotakeanactiveroleinthedecision-makingprocess.
• Theonlypreferencedrivingvariationsincareshouldbethatofthepatient.
• SDMisassociatedwithdecreasedanxiety,quickerrecovery,andincreasedtreatmentadherence.
• SDMinnovationsincludeelectronicdecisionaidsandinteractivetechnologiestoprovidepatienteducation.
StrategiesforImprovingPatientExperiencewithAmbulatoryCare.(2016)AgencyforHealthcareResearchandQuality,Rockville,MD.
Teach-BackTeach-Backisanevidence-basedhealthliteracyinterventionthatpromotesadherence,quality,andpatientsafety.
Patientsareaskedinasupportivemannertoexplain,intheirownwords,whattheyneedtoknow,ordo,afterdischargeasawaytocheckforunderstandingandtore-explaindischargeinstructionsifneeded.
AtHCPC,Teach-Backtechniquesareutilizedbytreatmentteammemberstoensure:• patientsunderstandmedicationinstructionsanddosage.• patientsunderstandtheiraftercareplansandhavesupportsinplacetoattendaftercareappointments.
http://www.teachbacktraining.org/
PeterD,RobinsonP,JordanM,LawrenceS,CaseyK,Salas-LopezD.Reducingreadmissionsusingteach-back:enhancingpatientandfamilyeducation.JNurs Adm.2015;45(1):35-42.
MedicationBestPracticesMedicationReconciliation• Processofcomparingapatient'smedicationorderstoallmedicationsthepatienthasbeentaking.
• Allpatientsreceivedetailedinformationaboutmedications.• Teach-backtechniquesareutilizedtoensurepatientsunderstandmedicationinstructions.
• Detailedinformationisprovidedtooutpatientprovidersandcaregiversasneeded.
MedicationFillandCounselingatDischarge• Patientsareprovidedwithfilledpsychiatricprescriptionsandmedicationcounselingfromthepharmacist,whichhasbeenassociatedwithreducedreadmissions.
TomkoJR,AhmedN,MukherjeeK,RomaRS,DilucenteD,OrchowskiK.Evaluationofadischargemedicationserviceonanacutepsychiatricunit.HospitalPharmacy.2013;48(4):314-320.
MotivationalInterviewing(MI)MIisapatientengagement,motivationalenhancement,andcounselingprocesswidelyusedinmentalhealthandsubstanceabusetreatment.
A1-hourMIsessionconductedpriortopsychiatrichospitaldischargehasbeenshowninpriorresearchtoimproveattendanceatthe1stoutpatientappointmentcomparedtotreatmentasusual.
HCPCpsychiatryresidents,socialworkersandpharmacistsaretrainedinMItechniquesusingtheOARSapproach(open-endedquestions,affirmations,reflectivelistening,andsummarizing).
AMIscriptthataddressestreatmentengagementandmedicationadherenceissuesisbeingpilotedatHCPC.
SwansonAJ,PantalonMV,CohenKR.MotivationalInterviewingandTreatmentAdherenceamongPsychiatricandDuallyDiagnosedPatients.JournalofNervous&MentalDisease.1999;187(10):630-635.
HCPC2016PilotInterventionsIn2016,evidence-basedinterventionswereimplementedwithpatientsfromoneofthetwotreatmentteamsontheHCPCSchizophreniaUnit(secondtreatmentteampatientsservedascontrols).
Theinterventiongroup(n=615)comparedtothecontrolgroup(n=513)hadreduced30-dayreadmissions(14%vs.20%;chi-square5.914;p=0.015).
SchizophreniaUnit2015
ReadmissionRate2016
ReadmissionRate
Intervention Group 17% 14%
ControlGroup 15% 20%
ProgramEvaluationMethods• Aspartoftheprogramevaluation,aRootCauseAnalysis (RCA)willbeconducted.
• TheRCAgoalistoidentifythefactorsresultinginHCPCreadmissionstodeterminewhatactionsand/orinactionsneedtobechangedtoreducereadmissionsandtoidentifylessonslearnedforfutureplanning.
• RCAwillprovidevaluableinformationaboutsystems-levelfactorsandsupportsleadingtoreadmissionsincludingwhypatientsarenon-adherentandbarrierstooutpatientengagement.
• Datatobeexaminedincludes:HCPCelectronicmedicalrecordandpatientandproviderinterviewdata.
Wilson,PaulF.;Dell,LarryD.;Anderson,GaylordF.(1993). RootCauseAnalysis:AToolforTotalQualityManagement.Milwaukee,Wisconsin:ASQQualityPress.pp. 8–17.
NewYorkStateOfficeofMentalHealth.ReducingBehavioralHealthReadmissions:StrategiesandLessonsLearned
MultidisciplinaryApproach• Therearemultipleopportunitiesforqualityimprovementinpsychiatricservices.
• Giventhecomplexnatureofseriousmentalillness(SMI)andthevulnerabilityoftheSMIpopulation,multidisciplinarycollaborationisvitaltothesuccessofourinitiative.
• Ourgoalistodevelopamultidisciplinaryapproachforourperformanceimprovementprojects:• EngagingallHCPCdisciplines/departmentsinthePIprojects• CreateaHCPCfaculty/staffworkgroupforeachPIproject• InvolvingHCPCfacultyphysiciansandpsychiatryresidentsinqualityresearch