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If at First You Don't Succeed...Build A Better Team - Waitlist Eliminated, and Immediate Crisis Response Service Developed at Yorkton Mental Health Services


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With the wait list eliminated, the Crisis Assessment Team (also known as CAT) has now evolved to not only respond to requests for service (elective or urgent), but also to be consistently abreast of all activity within the service.

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If at First You Don't Succeed...Build A Better Team - Waitlist Eliminated, and Immediate Crisis Response Service Developed at Yorkton Mental Health Services

  1. 1. If At First You Don’t Succeed, Build A Better Team Yorkton Mental Health Centre #QS14
  2. 2. Wait List Eliminated and Immediate Crisis Response Service Created Mental Health & Addiction Services, Sunrise Health Region
  3. 3. Introductions • Geraldine Koban, Manager of Inpatient Services and Crisis Assessment and Rehab Team • Kyla Shabatura, Team Leader, Crisis Assessment and Rehab Team • Sharon Stanicki, Supervisor of Health Information and Admin Services
  4. 4. Where We Work • The Yorkton Mental Health Centre provides both inpatient and outpatient services to clients with mental health and addictions issues • The service is located within the Sunrise Health Region with an approximate population base of 57,000 • There are approximately 90 staff members
  5. 5. Where We Work • Staff composition is made up of psychiatrists, community mental health nurses, registered psychiatric nurses, social workers, psychologists, addictions workers, and admin support and health information staff • Services are provided both at the main Yorkton Mental Health Centre campus and at 16 rural clinics throughout the region
  6. 6. What Services Do We Provide • Outpatient services provided include screening, crisis assessment, and treatment of mental health and addiction disorders, individual and family counseling, and group services • 15 bed inpatient psychiatric unit for persons requiring voluntary or involuntary admission for treatment of mental disorders
  7. 7. Who Do We Serve • Almost 22% of the region’s population is seniors 65 years and older • The First Nations communities within the region are predominantly concentrated in the northern part of the health region • The proportion of Aboriginal population grew faster in the Sunrise Health Region than in Saskatchewan • In the last decade the Aboriginal population has increased by 4.7%
  8. 8. Who Do We Serve • The perceived deterioration of mental health in the Sunrise Health Region is more apparent from previous years • In 2010 around 11% of persons aged 12 years or more rated their mental health as fair or poor • This is an increase from 2006 from when 7% of persons aged 12 years or more rated their mental health as fair or poor • Source of data: Sunrise Health Region 2012 Health Status Report
  9. 9. Intake Process • Three intake workers comprised of one clinician from each respective program of Adult Mental Health, Child & Youth Mental Health, and Addictions (both youths and adults) • Intake was done on a weekly and/or daily rotational basis depending on the specific program • Workers provided intake coverage in conjunction with managing their day-to day caseloads
  10. 10. Intake Process • Clients were triaged as elective, urgent, or emergent (no formal time lines for being seen) • Clients screened as not urgent or emergent would go straight to the wait list and a letter mailed out to them • Referrals were taken to a weekly meeting for discussion and possible assignment
  11. 11. Intake Process • Case assignment was voluntary and for the most part was program specific with a few exceptions • Client was not usually provided with a date for a first offered appointment • No one clinician was dedicated to intake
  12. 12. Intake Process • Walk-ins had to be managed within the worker’s intake rotation and their own clients • A provincial Mental Health & Addictions Kaizen around discharge transitioning was undertaken to determine system capacity and create a mechanism for client flow
  13. 13. Intake Process • In May 2012 the regions commenced reporting quarterly wait time metrics to the Ministry of Health • Four levels of urgency were established with accompanying benchmarks in which clients were to be seen: Very Severe, Severe , Moderate, and Mild
  14. 14. Intake Process • Regions were required to provide a corrective action plan on any decrease in meeting targets in the very severe and severe categories
  15. 15. A Day In the Life of Intake (Pre-CAT)
  16. 16. Issues, Challenges, and Obstacles • Intake was not consistent across the service with variations in each program area • Coverage was based on a rotational schedule that made no contingency plans for unexpected staffing changes/shortages • Inter-rater reliability issues triaging cases and in some cases referrals were incorrectly triaged
  17. 17. Issues, Challenges, and Obstacles • Assignment of most cases occurred weekly and based on staff voluntarily accepting referrals • Rural clients received first offered appointments sooner due to more clinic availability options • Difficulties directing incoming calls to intake workers
  18. 18. Issues, Challenges, and Obstacles • Inconsistent use of Outlook calendars for scheduling clients resulted in difficulties for reception staff directing client calls and appointments • Repeated requests for service where client presented with a higher acuity level and in some cases requiring to be admitted to inpatient psychiatric unit
  19. 19. Issues, Challenges, and Obstacles • No back up intake worker to accommodate heavier demand for services • Changing how wait list would be managed, i.e. change in directive, political implications • Poor response to service requests resulted in referrals being redirected elsewhere or no request for services
  20. 20. Issues, Challenges, and Obstacles • Staff rotated through intake while still being expected to handle their day-to-day duties instead of having staff dedication to intake • Staff apprehension/discomfort about doing intake • Inequitable workload for intake worker between programs
  21. 21. How Bad Was It • Huge wait list (120+) as of July 2013 • In 2013-2014 an average of 114 screenings were completed monthly with greatest concentration in Adult Mental Health Services • Staffing positions not filled • Not enough staff to be assigned cases
  22. 22. How Bad Was It • Incoming referral numbers combined with wait list numbers meant that intake input was greater intake output • Two other adverse events involves clients who committed suicide • One suicide of client who was on the wait list
  23. 23. How Bad Was It • Numerous client complaints • Multiple referrals on the same client who would often be re-referred with higher acuity levels the next time • Staff morale was negatively affected • Staff were encountering burn out
  24. 24. How Bad Was It • Near misses with clients being incorrectly triaged • Information regarding referral outcome was not communicated back to referring family physicians
  25. 25. How Bad Was It • Leadership problems within the service • Poor outcome measurement results being reported to the Ministry • Not meeting targets in the area of very severe and severe
  26. 26. Metrics and Evidence Based Statistics Pre-Cat • Average monthly screenings completed in 2012-13 fiscal year was 95 (Pre-CAT) • In the 2012-13 year 90 persons were added to the wait list at the time of referral/intake
  27. 27. % Met Target Wait Time by Program and Triage Level 2012-13 0 10 20 30 40 50 60 70 80 90 100 Very Severe Severe Moderate Mild Adult Addictions Adult Mental Health Child & Youth Addictions Child & Youth Mental Health
  28. 28. The Decision To Change • Ministry expectations for wait time measurements and reporting of results • Concern over adverse events • Current intake system not functional • Complaints around service accessibility • Staffing instability at the director level • Recruitment of new director who commenced March 2013 who provided direction and vision
  29. 29. Framework for The New Team • Selection of core Crisis Assessment Team • Criteria for team selection and identifying additional members • Preliminary discussion and then ongoing daily planning meetings • Creation of the Clinical Treatment Team
  30. 30. Framework for The New Team • Tackling the outstanding cases on the wait list • Mapping a plan for handling current incoming referrals • Determining intake schedule and roles of team members
  31. 31. Framework for The New Team • Caseload management for CAT members to make room for new roles • Use of Outlook calendars to facilitate communication and assignment of cases • Blurring of program lines to make the client the focus of service delivery
  32. 32. Framework for The New Team • Identifying obstacles and issues while still going ahead with a service delivery model in an informal structure • After some initial trepidation, the team embraced the change even with no formal model in place and continued to make adjustments along the way
  33. 33. The Crisis Assessment Team (CAT) Goes Live – Version 1.0
  34. 34. The Crisis Assessment Team (CAT) • Team composition – 3 RPN’s, 1 social worker, 1 addictions worker, and inpatient social worker • New interim manager brought on board mid September 2013 • Chief psychiatrist attends daily huddles • Community mental health nurses from Rehab attend as necessary
  35. 35. The Launch • CAT formally starts to operate as a service on September 3, 2013 • Daily team meetings • White boards and other visual management tools
  36. 36. The Launch • CAT attends HUB (local interagency committee) as a liaison • Inpatient social worker attends CAT to provide continuity of information flow between the inpatient unit and CAT
  37. 37. Team Mandate • Review and finalize strategy to tackle the wait list • Review and finalize how to handle incoming service requests • What is CAT and what does it do
  38. 38. Team Mandate • Who does CAT serve • How does CAT interact with other parts of the service • How does CAT interact with other agencies and service providers
  39. 39. Crisis and Assessment Process • Referrals were assigned based on available new appointment openings in individual workers’ calendars
  40. 40. A Day in the Life of CAT
  41. 41. The Team
  42. 42. Our daily visibility wall
  43. 43. Issues, Challenges, Obstacles • The commitment to reduce and eliminate the wait list took its toll on the core team losing two members • Communication struggles in the beginning during planning and development phase • Staff dissatisfaction at selection process
  44. 44. Issues, Challenges, Obstacles • Potential for future staff burnout needs to be part of team’s monitoring process, as once the service is shown to be more responsive and fluid in its service delivery, the demand for the service becomes greater • Lack of technology to assist in daily visual management
  45. 45. Issues, Challenges, Obstacles • Operation as an informal team initially created uncertainty and hesitancy with members • Increased responsiveness to service has now created increased demands for service delivery on the Clinical Treatment Team
  46. 46. Metrics - CAT • Average monthly screenings completed in 2013-14 was 114 (CAT begins operation informally August 2013) • 138 persons were placed on the wait list at the time of intake/referral in the first three quarters of the 2013-14 fiscal year • In March 2014 alone there were 188 screenings completed (CART) with 220 requests for service
  47. 47. Results by Triage and Program April 1, 2013, to September 30, 2013 Results are from April 1, 2013, to September 30, 2013, because of Ministry of Health directive to report quarterly 0 10 20 30 40 50 60 70 80 90 100 Very Severe Severe Moderate Mild Adult Addictions Adult Mental Health Child & Youth Addictions Child & Youth Mental Health
  48. 48. Results by Triage and Program October 1, 2013, to March 31, 2014 Results are from October 2013 to March 2014 because of Ministry of Health directive to change to monthly reporting 0 10 20 30 40 50 60 70 80 90 100 Very Severe Severe Moderate Mild Adult Addictions Adult Mental Health Child & Youth Addictions Child & Youth Mental Health
  49. 49. Evidence of Improvement Within 2013-14 0 10 20 30 40 50 60 70 80 90 100 Very Severe Severe Moderate Mild 80 42.5 27.2 24.7 100 100 95.5 95.7 1st Three Quarters Last Quarter Adult Mental Health
  50. 50. Progress • Wait list eliminated in less than two months October 2013 • Achieved 100% targeted wait times in all four levels of triage in November 2013 • Implementation of a red triage white board to track all clients who fell outside of target wait times
  51. 51. Progress • Significantly improved target results in wait times • An RPIW in October 2013 assisted CAT in streamlining some processes for case assignment • Change from quarterly to monthly reporting to the Ministry of Health for percentage of clients meeting target wait times
  52. 52. Sunrise MH&AS Triage Levels 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% Mild Moderate Severe Very Severe 62.37% 57.28% 72.41% 82.35% 94.40% 93.40% 100.00% 100.00% 2012-13 2013-14
  53. 53. CAT Reboot – CART (Crisis Assessment and Rehab Team) Version 2.0
  54. 54. The Team • Expanded the team in the fall of 2013 to further integrate Rehab into CAT • Increasing the scope of the team to include all the community mental health nurses from the Rehab service • Having clinical treatment team members attend daily meetings for communication sharing purposes
  55. 55. Team Mandate • In addition to acute crisis and assessment clients, CAT now provides back up coverage for Rehab clients when necessary • Daily monitoring the status of Rehab clients at risk • Keeping track of clients on community treatment orders and clients receiving long acting injectable medication
  56. 56. A Day In the Life of CART
  57. 57. Progress • The Addictions counselor from CAT provides support and coordination of care for the Methadone clients and Turning Points Program (needle exchange) • A member of CAT attends, when possible, discharge rounding at the Yorkton Regional Health Centre
  58. 58. Progress • Improved relationships with community partners and care providers • Addition of a dedicated depot clinic for clients receiving long acting injectable medication • The cost of the medication is subsidized by the Sunrise Health Region
  59. 59. Progress • Development of form letters to enhance communication between CAT and referring family physicians and nurse practitioners • Recent approval for SMART board to assist in daily visual management of our clients • Members from the Clinical Treatment Team now attend the daily morning huddle
  60. 60. Progress • Training of community mental health nurses to provide venipuncture for both community and inpatient psychiatric patients as necessary • Addition of a portable electronic vitals monitoring machine for outpatient mental health and addictions clients
  61. 61. The Future State of CART • Where is the team headed • As of April 1, 2014, CAT is screening all doctor-to- doctor referrals to Psychiatry
  62. 62. Final Thoughts • What did we learn from the experience • Giving credit where credit is due • What would we do differently … if anything
  63. 63. Faculty/Presenter Disclosure Faculty: Geraldine Koban, Kyla Shabatura, Sharon Stanicki Relationships with commercial interest: • Not applicable
  64. 64. Disclosure of Commercial Support • This program has received financial support Not Applicable Potential for Conflict(s) of Interest: • Not applicable
  65. 65. Mitigating Potential Bias • Not applicable
  66. 66. Questions ? Contact Me: Geraldine Koban Manager, Inpatient Services and CART Sunrise Mental Health & Addiction Services #QS14