Improving Healthcare Quality: Advanced Clinic Access in Mental Health Mary Schohn, Ph.D. April 24, 2004

Background Quality of healthcare is determined by the design of the healthcare system (Berwick, 2003). Three major gaps in the current delivery of healthcare are: (IOM, 2001) Overuse of procedures that do not help people get better Under use of procedures that can help Misuse or errors

Roadmap to improvement Identify gaps between current performance and desired performance Seek new designs Involve everyone (Berwick, 2003)

VHA/IHI Collaborative Started in 1999 Goals Reducing Delays and Wait Times by 50% in six pilot clinics Redesign clinic scheduling based on model of open access Spread across all of VHA

Improvement in Average Next Available Appointment

Reduction in Wait Times While Patients Increase

Mental Health and ACA Directors Performance Measure FY04 Added three Mental Health Clinics ( 502, 509, 510) to the ACA Initiative for reducing waiting times Directors Performance Monitors FY04 Number of clinics with wait time greater than 45 days includes 502,513,531,540 and 547 Number of patients waiting more than 30 days beyond the their desired appointment date. Percentage of appointments scheduled as next available compared to the national average for the MH Performance clinics. No show rates

Current status

Common Strategies Used in Mental Health ACA in VA Match Supply and Demand Measure supply and Demand Define supply Sum of clinic slots Based on FTEE assigned to clinic Panel sizes Define demand Sum of consults, walk-ins, calls for appointments, rebooks

Common Strategies used in Mental Health ACA in VA Match Supply and Demand Reduce appointment types Review appointment types to see if efficiencies can be gained by eliminating appointment types; eg. Reduce/eliminate intake appointments; provider who does initial assessment provides the ongoing care; 30 minute appointments only; triage appointment completes the intake appointment.

Common Strategies used in Mental Health ACA in VA Match Supply and Demand Plan for contingencies Be aware of seasonal variation in demand and supply Plan for variations; develop time off policies to ensure coverage; cross coverage arrangements

Common Strategies Used in Mental Health ACA in VA Shape the Demand Work Down the Backlog Hire temporary staff; detail staff, use OT Review provider schedules Reduce other demands on providers time temporarily

Common Strategies used in Mental Health ACA in VA Shape the Demand Reduce the Demand Reduce return rate visits whats the value of the next appointment? Increase graduation rates Develop specialty agreements Reduce no-show rate Reduce automatic rebooks for no-shows Increase group visits Make the first visit count

Common Strategies Used in Mental Health ACA in VA Redesign system to increase supply Manage the constraint Figure out the bottleneck in the process eg. Lack of intake slots; drop-ins; telephone calls; documentation time

Common Strategies Used in Mental Health ACA in VA Redesign System to Increase Supply Optimize the care team Review team functions and assignments – dont have MDs doing work that clerks or nursing staff can do eg. AIMS, care coordination, scheduling; use of dictation Redistribute case load to mid-levels

Common Strategies Used in Mental Health ACA in VA Redesign System to increase supply Predict and anticipate patient/system needs at time of appointment Max packing- ensure clinical reminders are done at time of visit Depression follow-up preset orders

Common Strategies Used in Mental Health ACA in VA Redesign System to Increase Supply Synchronize patient, provider and information Improve consult requests Optimize rooms and equipment eg. Telepsychiatry in CBOCs

Role for Psychology Leaders Make it a priority Develop Teams Review actions Aims and goals Monthly progress report Plans for testing and implementing changes Provide for spread activities and opportunities Identify opinion leaders

Role for Psychology leaders Empower and Support Champions Promote the project Publicize team achievements Present outcomes at regional/national meetings Convert resistance Research outcomes Become a Clinical Coach

Resources ACA Liaison to MHSHG Robert Gresen, Ph.D. MH Liasion to ACA Steering Committee Mary Schohn, Ph.D. ACA website ACA MH Monthly Conference Calls

Resources VISN MH POC MH ACA Mail group MH ACA Satellite Videoconference August, 2004