1. Crisis Residential Best Practices Toolkit
February 17, 2017

2. 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.

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

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

5. 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.

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

7. 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. 

8. Measure sets in healthcare
Various payers and accrediting organizations publish standardized measure sets for use in healthcare including
CMS:
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.

9. 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.”

10. 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.

11. 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

12. 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

13. 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

14. 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),

15. 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.

16. Metrics & Outcomes Results: Customer Satisfaction

17. 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

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

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

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

21. 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.”

22. Metrics & Outcomes Results: Structure of Data Collected

23. 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.”

24. 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

25. Metrics & Outcomes Results: Employee Satisfaction

26. Metrics & Outcomes Results: Employee Satisfaction

27. 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)

28. National Council Conference- Crisis Meetup
Tuesday, April 4:30pm
Location: To Be Determined
Interested?

29. 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

30. Next Steps
Next Conference Call: Wednesday, March 2pm EST/11am PST Group Listserv: Website: (Meeting Slides stored here) Questions: