The Jim Taliaferro Community Mental Health Center faced challenges with physician shortages that led to short patient stays and risks to CMS certification. A team developed a new Admissions & Evaluation Services Unit with the goals of reducing costs, improving processes, and ensuring compliance. The remodeled unit features separate entrances, comfort rooms, and evaluation offices. These changes decreased emergency admissions, increased average patient length of stay and staffing efficiencies, saving over $230,000 while enhancing the quality of care.

1. Transforming the Concept,Process & Environment ofJim Taliaferro CMHC Admission & Evaluation Services Unit

2. IntroductionThe 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.Our Coverage AreaCIMARRONTEXASBEAVERWOODSOTTAWAHARPEROSAGEKAYGRANTNOWATAWASHINGTONCRAIGALFALFAELLISWOODWARDGARFIELDNOBLEDELAWAREMAYESROGERSMAJORPAWNEETULSAPAYNEKINGFISHERDEWEYBLAINEWAGONERCREEKCHEROKEELOGANLINCOLNADAIRROGER MILLSMUSKOGEECUSTEROKMULGEEOKLAHOMASEQUOYAHCANADIANOKFUSKEEMcINTOSHBECKHAMCADDOWASHITAPOTTAWATOMIESEMINOLEHASKELLCLEVELANDHUGHESGRADYKIOWAGREERPITTSBURGMcCLAINLEFLORELATIMERPONTOTOCHARMONGARVINCOMANCHEJACKSONCOALSTEPHENSTILLMANMURRAYPUSHMATAHAJOHNSTONATOKACARTERCOTTONJEFFERSONMcCURTAINCHOCTAWMARSHALLLOVEBRYAN

3. The ChallengeDuring 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.$ 1,000,000In Funding inJeopardy No PhysicianCoverageThe 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 ofBad EDAdmits

4. 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 DirectorMike Strickland, MD Clinical DirectorJudy Wallace, Process ImprovementVictor Wilkerson Inpatient DirectorEllie Cruz, RN Director of NursingJill Melrose Evaluations Unit CoordinatorRandy Kauk Senior Evaluation Specialist

5. Our GoalsA 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:Reduce crowding, wait times, and the number of patients who leave without being seenImprove the Emergency Detention Admission Process to provide better integration with Law Enforcement AgenciesCreate a staffing plan that reduces costs and increases coverage during peak hours.Develop call-coverage strategies and closer alignment with key physiciansProvide better patient and staff safety while increasing overall program satisfactionExpand and remodel the Evaluation UnitProvide comfort rooms to consumers and law enforcement personnel to make any wait times more tolerable

6. MethodsTo 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. PDSA3 Model$230k+ inPayroll Saved!ReducedOperatingCostTotal CMSCompliance!

7. Methods

8. The SolutionThe newjimtaliaferrocmhcAdmission & evaluation services unit

9. How it works1. Consumer is transported to our facility.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.

10. How it worksAdding 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.

11. How it works2. They are welcomed to our newly remodeled Admissions & Evaluations UnitOn the new Unit, confidentiality is maintained and the consumer does not enter the Inpatient Unit unless admitted.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)

12. How it worksLaw Enforcement &Department of CorrectionsareWELCOMEHere 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.

13. How it works3. Consumer is evaluated, and if criteria is met, admitted by friendly and concerned staff. 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)

14. ResultsEnhancedQuality ofCareDecreasedE.R. & JailFor Consumers48%More M.H. BedsAvailableNo AdverseTreatmentStays of < 24 hours cut in half

15. Increased ALOS from 2-3 days to 4-5 days

16. Decreased wait time for evaluations

17. Increased consumer satisfaction

18. Improved relations with law enforcement