Crisis Residential Best Practices Toolkit February 17, 2017

Today’s Agenda Roll Call Crisis Home Spotlight: Steve Fields (Progress Foundation- San Francisco, CA) Content Overview: Metrics & Outcomes Crisis Metrics: Margie Balfour, Connections AZ Review Survey Results/Discussion Review Project Plan and Timeline Adjourn Housekeeping: Using Skype for questions Purpose: To develop a comprehensive Best Practice Toolkit for Crisis Residential Services, informed by Crisis Residential providers across the country.

www.TBDSolutions.com Crisis Program Development Quality Improvement Research & Analysis Integrated Care Coordination Data Analytics System Redesign Management Training Metrics Development www.TBDSolutions.com

Workgroup Participants 80 homes from 28 states participating Plus England! Approximately 300 crisis homes nationwide

Crisis Home Spotlight: Progress Foundation Steve Fields, MPA Executive Director, Progress Foundation Executive Director of Progress Foundation since 1969, Steve Fields has championed the development of social rehabilitation programs throughout California and the nation, pioneered acute residential alternatives to hospitalization, opened the first social model residential treatment programs for geriatric clients and the first social model residential treatment program for women and children. He received his BA from Harvard and a Masters of Public Administration from the University of San Francisco. A leader in local, state and national efforts to develop and promote change in the mental health system, he was instrumental in forming the San Francisco Human Services Network (HSN), an association of over 100 nonprofit agencies.

Today’s Topic: Metrics and Outcomes Customer Satisfaction Outcome Measures Process Measures Challenges/Barriers to Collecting Metrics Employee Satisfaction

Crisis Metrics Development Margie Balfour, MD, PhD VP for Clinical Innovation and Quality, ConnectionsAZ (Arizona)  I started off as a scientist, then developed a passion for clinical work in public sector behavioral health, particularly with crisis/psychiatric emergency services and high utilizers. I became interested in performance improvement as I realized that the story behind every person I saw in the ER indicated an opportunity for improvement in the community behavioral health system.  I use my clinical, research and quality improvement background to lead the design, development and implementation of data driven and quality focused operations that deliver care that is safe, effective, and recovery-oriented. I facilitate collaborative partnerships between diverse stakeholders to identify opportunities for improvement, and as a physician-scientist, take a deep dive into data to ensure integrity in assessing and developing solutions. 

Measure sets in healthcare Various payers and accrediting organizations publish standardized measure sets for use in healthcare including CMS: http://hospitalcompare.hhs.gov The Joint Commission Core Measure Sets Hospital-Based Inpatient Psych, Emergency Medicine, etc. NCQA Healthcare Effectiveness Data and Information Set (HEDIS) National Quality Forum But none include a set of standardized measures defining desired outcomes specifically for crisis or emergency psychiatric services.

Why is crisis left out? There is no standard definition of crisis services Free-standing, within a medical ED, or mobile? 23-hour or 72-hour stabilization or longer? Inpatient or outpatient licenses? Locked or unlocked? Crisis services fly under the federal radar Medicare doesn’t pay for it Crisis services are typically paid for and regulated by state and local behavioral health or Medicaid systems “If you’ve seen ONE state behavioral health system, you’ve seen ONE state behavioral health system.”

Developing a crisis measure set (because necessity is the mother of invention) We operate 2 similar (but not identical) programs in Phoenix and Tucson. Both are facility-based crisis programs with psych urgent care, 23 hour obs, and short-term inpatient services 23 hr obs receives ~900/month highly acute patients from police, transfers from EDs, and walk-ins Differences included: adults vs. kids, academic medical center, peers, inpatient vs. outpatient license, integrated care We also provide consultation to help others develop crisis and emergency psychiatric services. So we needed a way to compare outcomes across various programs.

Translating values into metrics A Critical-To-Quality (CTQ) Tree is a quality improvement tool used to translate values into discrete measures Broadly, what value are you trying to accomplish? Then what are the key attributes that make up that value, from the perspective of the customer? Then define measures that reflect each attribute

Metrics go here. Values-Based Outcome Metrics Timely Safe Accessible Least Restrictive Partnership Effective Accessible Consumer and Family Centered Metrics go here. Excellence in Crisis Services

Metrics Primer: Donabedian Model Structure Measures refer to the environment in which care is delivered – a facility’s organization and resources. “What do you HAVE?” Is there a psychiatrist co-located in a primary heath clinic Staff to patient ratios Process Measures refer to the techniques and processes used to treat patients. “What do you DO?” % patients screened for depression Door to balloon time for Acute MI Outcome Measures refer to the consequences of the patient’s interaction with the healthcare system “Does it WORK?” Mortality Patient Satisfaction Improvement on depression rating scales Readmissions Dr. Avedis Donabedian 1919-2000

Choosing Metrics Meaningful: Does the measure reflect a process that is clinically important? Is there evidence supporting the measure? Feasible: Is it possible to collect the data needed to provide the measure? If so, can this be done accurately, quickly, without a need for excessive manual data entry or chart audits? Actionable: Do the measures provide direction for future quality improvement activities? Are the factors leading to suboptimal performance within the span of control of the organization to address? Hermann RC, Palmer RH (2002). Common ground: a framework for selecting core quality measures for mental health and substance abuse care. Psychiatr Serv, 53(3), 281-287.

Values-Based Performance Metrics CRISES: Crisis Reliability Indicators Supporting Emergency Services Excellence in Crisis Services Timely Safe Least Restrictive Door to Diagnostic Evaluation Left Without Being Seen Median Time from ED Arrival to ED Departure for ED Patients: Discharged, Admitted, Transferred Admit Decision Time to ED Departure Time for ED Patients: Admitted, Transferred Rate of Self-directed Violence with Moderate or Severe Injury Rate of Other-directed Violence with Moderate or Severe Injury Incidence of Workplace Violence with Injury % Community Dispositions % Conversion to Voluntary Status Hours of Physical Restraint Use Hours of Seclusion Use Rate of Restraint Use Partnership Effective Unscheduled Return Visits – Admitted, Not Admitted Law Enforcement Drop-off Interval Hours on Divert Provisional: Median Time From ED Referral to Acceptance for Transfer Post Discharge Continuing Care Plan Transmitted to Next Level of Care Provider Upon Discharge Provisional: Post Discharge Continuing Care Plan Transmitted to Primary Care Provider Upon Discharge Denied Referrals Rate Provisional: Call Quality Accessible Consumer and Family Centered Consumer Satisfaction – % Likely to recommend Family Involvement - % attempt documented Balfour ME, Tanner K, Jurica PS, Rhoads R, Carson C. (2015) Community Mental Health Journal. 52(1): 1-9.http://link.springer.com/article/10.1007/s10597-015-9954-5

Metrics & Outcomes Results: Customer Satisfaction

Metrics & Outcomes: Customer Satisfaction Comments: Using online surveys as an option (i.e. SurveyMonkey) Using iPads or kiosks as collection methods Using the same survey at discharge and at 30-day follow-up

Metrics & Outcomes Results: Customer Satisfaction Data used to in support of CARF accreditation Utilize data to seek funding sources, financial supports, and enhance collaborations

Metrics & Outcomes Results: Outcome Measures Other tools used: MHSIP Columbia Suicide Risk Assessment Magellan CHI Colorado Client Assessment Record CAGE Scores

Metrics & Outcomes: Process Measures “We barely have enough staff to provide services to clients.”

Metrics & Outcomes Results “Our EHS pulls data automatically for length of stay averages and can split this out into a bunch of different categories.” “We also collect AMA discharges.”

Metrics & Outcomes Results: Structure of Data Collected

Metrics & Outcomes Results: Challenges to Collecting Metrics “Need qualitative measures, but difficult to find one good fit that is very low or no cost.” Still awaiting health information exchange implementation in order to better track outcomes once an individual leaves our facility.” “Hiring for the right personnel.” “Currently too difficult as a manual process.”

Crisis Metrics Spotlight: Michigan Michigan Crisis Residential Network Began collecting metrics in June 2016 Measures collected: Recidivism, LOS, LOS <7 days, Discharge disposition Poster Session at National Council Conference in April

Metrics & Outcomes Results: Employee Satisfaction

Metrics & Outcomes Results: Employee Satisfaction

Project Participation: Update Meeting participation: Monthly phone calls geared towards specific crisis topics to be included in the toolkit, engage in dialogue with providers from other areas to understand nuances in state policy and provider practice while building consensus for best practices. Content submission: Each month, all participants will be polled about their crisis home’s policies, procedures, and practices, which will be used to inform the toolkit Content/editorial review: Initial content reviews will now be completed by the planning team. State policy research: Seek out crisis residential statutes in your state, as well as other governing bodies (e.g. Adult Foster Care, Recipient Rights)

National Council Conference- Crisis Meetup Tuesday, April 4th @ 4:30pm Location: To Be Determined Interested? Email travisa@tbdsolutions.com

For March: Community Relations and… Taxonomy? Marketing, PR, Managing Relationships with Providers and Partners Classifying and Categorizing our Crisis Services to better understand one another’s programs and functions

Next Steps Next Conference Call: Wednesday, March 15th @ 2pm EST/11am PST Group Listserv: CrisisResidentialNetwork@TBDSolutions.com Website: www.CrisisResidentialNetwork.com (Meeting Slides stored here) Questions: TravisA@TBDSolutions.com