One Plan, Three Goals:  Optimize Care, Optimize Productivity and Optimize Revenue Tracy Abzug, LCSW-S, Practice Manager Hilary Carr, MSW, Program Specialist Crisis Residential Conference, October 2019 

Objectives Learn 1 Be 2 3

Why? Who? To implement an effective system that prioritizes high quality care while meeting revenue cycle requirements within three different levels of residential care (Extended Observation Unit - Involuntary, Crisis Residential, and Respite).  Revenue streams for residential services are limited, which means it is necessary to ensure program procedures maximize billing opportunities while supporting quality care. Director of Project Management* Project Lead  Director of Crisis Services  Director of Reimbursement Medical Director  Unit Managers  Unit Team Leads  Nurse Supervisors Service Providers Problem identified from the business side of the house. Identified numbers not reflective of care provided. Crux of project was to bridge the gap between the numbers and the actual quality of care being provided while hoping these efforts improve revenue. F2F always at the heart of the project – know this is where the quality care is.

Crisis Levels of Care Extended Observation Crisis Residential Crisis Respite Extended Observation Unit: Provide up to 48 hours of emergency services to people in a MH crisis who might pose a high to moderate risk of harm to themselves or others. EOUs can accept people on Emergency Detention. Crisis Residential Unit: Provide community based residential crisis treatment to people with a moderate to mild risk of harm to themselves or others, who might have fairly severe functional impairment, and whose symptoms cannot be stabilized in a less intensive setting. CRUs are not authorized to accept people on involuntary status Crisis Respite Services: Provide community based residential crisis treatment for people who have a low risk of harm to themselves or others, and who might have some functional impairment who require direct supervision and care but do not require hospitalization. Services can happen over a brief period of time and generally serve people with housing challenges or assist caretakers who need short-term housing or supervision for people they care for to avoid mental health crisis. Respite facilities are not authorized to accept people on involuntary status.  # of total beds, # of total staff involved in the project, # of clients served annually Crisis Levels of Care

Project Phases (H) Phase 1: Phase 2: Phase 3: Capturing snapshot and visual representation for managers, meet with ind. Program manager to layout workflow (T) Phase 4: Unit-wide meeting with PowerPoint, charter, baseline data – rally to get people to buy in. Phase 5: Weekly reporting, check-ins, identify sticking points and identifying next steps to overcome Phase 6: Wrap- up meeting, review project, identify aspects that didn’t contribute to meeting the goal – allowing for the program to continue efforts.

Proposed Procedural Changes Scheduled services (LPHA & QMHP differences) Drop-in hours Uniform Pass Policy Monitoring & Collaboration Proposed Procedural Changes 1) Res settings not appointment based bc of nature of crisis setting – perceived need to have flexibility to address needs as they came up, while having comfort in knowing clients are in a secured environment which makes them available as the team member is available – this reactionary approach left some clients to get less face to face than those who better self-advocates. Scheduling services flips that on it’s head and forces the tx team to proactively address client’s needs. 2) Recognized the amount of unanticipated visits from ongoing care teams did 1 of 2 things. 1) did not allow tx team to effectively collaborate because they were with another client, or Designated 2 hour window at each site for ongoing care teams to meet with clients and clinician on-site along with scheduling option.

On the Ground Staff Kickoffs MI training Collaborative documentation Weekly meetings between individual staff and TL Weekly meetings between TL and Unit Managers Weekly manager check-in calls Client and staff preparation On the Ground

Essential Change Management Plans 1) A tenured staff had more difficulty with changing habits/adjusting routines. Manager individually met with staff to identify and discuss the barriers, provide encouragement, and concrete steps to monitor individual towards change. Individual weekly check-ins were necessary to work through this. 2) Holding selves accountable to practicing collab. documentation. Some staff needed intensive in-vivo coaching to increase confmort.

Project Outcomes Optimize Client Care: Optimize Productivity: Client intervention times have increased by 10-20% Pass planning increased successful appointments in the community Increased coordination between crisis residential and ongoing care teams Optimize Productivity: Up to 10% increase in face-to-face service time Optimize Revenue: This was an opportunity to implement changes that affect the first two goals and despite not seeing a notable revenue increase we now have the evidence to advocate for different pay structures

Challenges Fee for service vs bed day service Staff turnover Philosophical differences (hours worked/hours paid) Cultural shifts Reactive vs. proactive Balancing uniformity among programs while respecting inherent differences based on levels of care 

Lessons Learned Slow burn rollout turned out to be helpful Know your internal resources  Building understanding – management change team Project management – clinic based vs residential services Lessons Learned

Successes Manager Checklist LPHA role Nurse client contact Structure changes culture by respective staff need for self-care by building in time  More to come Staff retention?  Successes

Questions