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  • Talk slated to be done by Dr. Sethi …….. I have been at CMHI for 7 years We are in NW part of the state & Serve 41 counties for Adults 56 counties for Children & Adolescents We have 24 locked unit beds, 22 open unit beds and 12 children & Adolescent beds Several Areas of change – some at the central level most changes that we have made in response to the needs of patients
  • -Decrease is in admission/year or total in 2 years -unable to admit community emergencies
  • Using out of state agencies for children who needed longer care
  • Review all patients with longer than 6 month hospital stay
  • Multiple Diagnosis on different Axis Legal Issues – Risk to public
  • Change in Guidelines for Treatment Plan – change to active goals and treatment Relationship with RCF/PMI units – improved with exploration of resistance to accepting patients – we will not take them back Change in Philosophy for Admission Criteria – from Reactive to Proactive Reciprocal Court Orders – ex about having to wait hours for court order
  • Example about patient’s staying in R or S for upto 4 hours if adult “ we still have 1 hour before the order is up”
  • Sanctuary Model - Decrease in Trauma re-experience Quiet Room Soft toys Empowering the ward staff to help bring about the change and not feel that they would be penalized for suggesting alternate approaches Social workers are available on the weekend – one day to help with PRP activities
  • With the help of PA students and we made a video of case vignettes of actual staff interaction that was considered to be non therapeutic
  • Decrease response time from 2.5 min to less than 30 secs
  • Power Point Presentation

    1. 1. Changing Times at CMHI Simrat Sethi, M.D. Interim Clinical Director 2/13/2008
    2. 2. CMHI Catchment Area Children/Adolescent (56 counties)
    3. 3. CMHI Catchment Area Adults (41 counties)
    4. 4. Cherokee MHI <ul><li>Reorganization of Children & Adolescent Services </li></ul><ul><li>Impact of Olmstead Decision </li></ul><ul><li>Restraint Seclusion Reduction </li></ul><ul><li>Patient & Employee Injuries from Patient Assault </li></ul><ul><li>Inpatient Bed Utilization </li></ul><ul><li>Physician Assistant Psychiatric Education Program </li></ul>
    5. 5. Reorganization of Children &Adolescent Services (2002) <ul><li>Length of Stay Impact on Admissions </li></ul><ul><ul><li>Greater length of stay = less admissions </li></ul></ul><ul><ul><li>Less admissions = less quality care </li></ul></ul><ul><li>Resulting Problem – Admissions were: </li></ul><ul><ul><li>Community Emergencies </li></ul></ul><ul><ul><li>Placement of Last Resort </li></ul></ul>
    6. 6. Reorganization of Children &Adolescent Services (cont.) <ul><li>Solution </li></ul><ul><li>Re-define Admissions </li></ul><ul><ul><li>Appropriate 0 – 21 days </li></ul></ul><ul><ul><li>Questionable 22 < 60 days </li></ul></ul><ul><ul><li>Inappropriate > 60 days </li></ul></ul><ul><li>Educate CPC’s, Juvenile Court Officials, Foster Care, Child Protective Programs </li></ul>
    7. 7. Reorganization of Children &Adolescent Services (cont.) <ul><li>Result </li></ul><ul><ul><li>Steady increase in admissions </li></ul></ul><ul><ul><li>Greater number of appropriate admissions </li></ul></ul><ul><ul><li>Serving more counties 19 before to over 31 now </li></ul></ul><ul><ul><li>Average Length of Stay dropped </li></ul></ul>
    8. 8. Children & Adolescent LOS and Admissions
    9. 9. Impact of Olmstead Decision <ul><li>Under ADA persons should be placed in Community if: </li></ul><ul><ul><li>They do not need institutional level of care </li></ul></ul><ul><ul><li>Do not wish to remain in institution </li></ul></ul><ul><li>Goal – Identify Barriers to Discharge </li></ul>
    10. 10. Impact of Olmstead Decision (cont.) <ul><li>Identified Barriers </li></ul><ul><ul><li>Treatment Resistant Illness </li></ul></ul><ul><ul><li>Multiple Diagnosis </li></ul></ul><ul><ul><li>Non-compliance with Treatment </li></ul></ul><ul><ul><li>Chronic Illness </li></ul></ul><ul><ul><li>Legal Issues </li></ul></ul><ul><ul><li>Community Resistance to Placement </li></ul></ul>
    11. 11. Impact of Olmstead Decision (cont.) <ul><li>Changes </li></ul><ul><ul><li>Change in Guidelines for Treatment Plans </li></ul></ul><ul><ul><li>Grand Staffing for Difficult Clinical Situations </li></ul></ul><ul><ul><li>Relationship with RCF/PMI units </li></ul></ul><ul><ul><li>Change in Philosophy for Admission Criteria (Reactive to Proactive) </li></ul></ul><ul><ul><li>Reciprocal Court Orders </li></ul></ul>
    12. 12. Number of Patients with Length of Stay Greater Than Six Months
    13. 13. Restraint Seclusion Reduction <ul><li>Committee started work in October 2000 </li></ul><ul><li>Goals of </li></ul><ul><ul><li>Reducing and eliminating R&S, </li></ul></ul><ul><ul><li>Enhancing patient and staff safety, </li></ul></ul><ul><ul><li>Eliminate re-traumatizing patients </li></ul></ul>
    14. 14. Restraint Seclusion Reduction (cont.) <ul><li>Findings: </li></ul><ul><ul><li>R&S continued till maximum permitted time instead of earliest termination. </li></ul></ul><ul><ul><li>No pattern to shift, units or staff R&S. </li></ul></ul><ul><ul><li>Staff Concerns </li></ul></ul><ul><ul><ul><li>Increase in staff & Patient injury rate “if we do not Seclude or Restrain preemptively” </li></ul></ul></ul>
    15. 15. Interventions <ul><li>Every R&S episode administratively reviewed. </li></ul><ul><li>Feedback given to staff involved. </li></ul><ul><li>Training changed from Mandt to Pro-Act. </li></ul><ul><li>Predicting, preventing and monitoring agitation in patients, skill in de-escalation techniques. </li></ul>
    16. 16. Interventions (cont.) <ul><li>Monthly newsletter for staff. </li></ul><ul><li>Information on usage, educational information, alternative strategies. </li></ul><ul><li>Nationwide benchmarks and experience from other facilities. </li></ul>
    17. 17. Interventions (cont.) <ul><li>Sanctuary Model </li></ul><ul><li>Loosening up of ward rules </li></ul><ul><li>Availability of phone calls </li></ul><ul><li>Food and fluids policy </li></ul><ul><li>Physician availability </li></ul><ul><li>Social Worker availability </li></ul>
    18. 18. Restraint/Seclusion Usage
    19. 19. Comparison of Staff Injuries related to Patient Restraint 61 69 22 16 18 11 8 9
    20. 20. Results of Staff Injuries related to Patient Restraint
    21. 21. Injuries from Patient Assault <ul><li>New Initiatives </li></ul><ul><ul><li>Therapeutic Communication </li></ul></ul><ul><ul><li>Use of Verbal interventions at emergencies </li></ul></ul><ul><ul><li>Use of Protocols </li></ul></ul><ul><ul><ul><li>involving patients in the management plan </li></ul></ul></ul><ul><ul><li>Grand Rounds </li></ul></ul><ul><ul><li>Cooperation with local law enforcement </li></ul></ul>
    22. 22. Injuries from Patient Assault (cont.) <ul><li>Improved emergency call system </li></ul><ul><li>Debriefing after the incident </li></ul><ul><li>Decrease beds on locked units from 18 –12 </li></ul><ul><li>Assault on Health Care Worker </li></ul><ul><ul><li>Class D Felony </li></ul></ul><ul><li>Reduction of Restraint & Seclusion </li></ul><ul><li>Anger Management Classes </li></ul>
    23. 23. Injuries from Patient Assault (cont.) <ul><li>“Conventional Wisdom” challenged </li></ul><ul><ul><li>“Patient assault cannot be prevented” </li></ul></ul><ul><ul><li>“R&S reduces assaultive behavior” </li></ul></ul><ul><ul><li>“Mentally ill are not legally responsible for assaults” </li></ul></ul>
    24. 24. Comparison of Staff Injuries related to Patient Assault 1 9 6 2 1 2 1 0 7 32 37 51 51 45
    25. 25. Results of Staff Injuries related to Patient Assault
    26. 26. Inpatient Bed Utilization <ul><li>Lack of beds and longer waiting lists </li></ul><ul><li>Changed from gender specific to co-ed units in Jan 2007 </li></ul><ul><li>Consulted staff from Clarinda who run a co-ed unit </li></ul><ul><li>Workgroup of unit staff tackled concerns, rules, logistics </li></ul>
    27. 27. Inpatient Bed Utilization (cont.) <ul><li>Concerns included patient supervision, sexual acting out, disinhibition </li></ul><ul><li>Consistent access to phone, caffeine, snacks and privileges across the units </li></ul><ul><li>Direct care staff involvement in planning, problem solving and implementation was key to success. </li></ul>
    28. 28. Adult Patients LOS and Admissions
    29. 29. Physician Assistant Training Program <ul><li>Reason </li></ul><ul><li>Resources </li></ul><ul><li>Challenges </li></ul><ul><li>Recruitment </li></ul><ul><li>Placement </li></ul>
    30. 30. Reason <ul><li>Lack of physician providers in rural Iowa </li></ul><ul><li>Cherokee MHI had a previous psychiatry residency program </li></ul><ul><li>Federal grant obtained. </li></ul>
    31. 31. Resources <ul><li>Staff Psychiatrists </li></ul><ul><li>Inpatient Units </li></ul><ul><li>Outpatient Experience at CMHCs </li></ul><ul><li>On Call Experience </li></ul><ul><li>Didactics include lectures, case presentations and discussions, observed patient interviewing </li></ul>
    32. 32. Challenges <ul><li>Drying up of federal funds after 2002 </li></ul><ul><li>Restarting recruitment after obtaining state funding </li></ul><ul><li>Finding suitable candidates </li></ul><ul><li>Psychiatrist attrition at the MHI </li></ul><ul><li>We have lost a clinical director and 2 out 4 psychiatrists this year </li></ul>
    33. 33. Recruitment <ul><li>Physician Assistant conferences </li></ul><ul><li>Web Site </li></ul><ul><li>Local Mental Health Provider referrals </li></ul><ul><li>PA students rotating through the MHI </li></ul><ul><li>Self referrals from the website </li></ul>
    34. 34. Placement of Graduates <ul><li>Preferred placement in rural Iowa </li></ul><ul><li>50% in-of-state placements </li></ul><ul><li>3 out 3 recent graduates are working in north west Iowa </li></ul><ul><li>How do we make rural Iowa an attractive destination for practicing psychiatry? </li></ul>
    35. 35. Future Areas <ul><li>Fall Reduction </li></ul><ul><li>Suicide Assessment and Prevention </li></ul><ul><li>How to address? </li></ul><ul><ul><li>Formal Assessment </li></ul></ul><ul><ul><li>Communication </li></ul></ul><ul><ul><li>Environmental Safety </li></ul></ul>
    36. 36. Impact of Changes on Patient Care (cont.) <ul><li>Improved ability to admit by </li></ul><ul><li>effective bed utilization </li></ul>
    37. 37. Impact of Changes on Patient Care (cont.) <ul><li>Monitoring patient stay and ensuring that patients are discharged to the least restrictive setting. </li></ul>
    38. 38. Impact of Changes on Patient Care (cont.) <ul><li>Positive work environment and ongoing staff training has lead to </li></ul><ul><ul><li>Decrease in assaults & injuries </li></ul></ul><ul><ul><li>Work towards the elimination of Restraint & Seclusion </li></ul></ul><ul><ul><li>Continued building of a team approach </li></ul></ul>
    39. 39. Impact of Changes on Patient Care (cont.) <ul><li>Help ensure good quality psychiatric care by training PA’s/ARNP’s. </li></ul>
    40. 40. Admissions Adult/Children/Adolescent
    41. 41. Average Daily Census Adult/Children/Adolescent
    42. 42. Thank You! The End