1. Strategies for Success NYSOMH Quality Improvement Initiative

2. Overview Welcome and Introductions Welcome and Introductions Agency Presentations Agency Presentations Cardiometabolic Risk: Long Island Consultation Center Cardiometabolic Risk: Long Island Consultation Center Polypharmacy: Federation of Organizations Polypharmacy: Federation of Organizations Questions and Answers Questions and Answers

3. Long Island Consultation Center QI Point: Elaine Lederer Executive Director Project: Cardiometabolic Risk

4. Clinic Structure Clinic prescribers: 5 part-time psychiatrists (shared with OASAS program) Clinic prescribers: 5 part-time psychiatrists (shared with OASAS program) Medical Director oversees psychiatrists, but they do not meet as a team. Medical Director oversees psychiatrists, but they do not meet as a team. Clients see psychiatrist monthly; individual therapy is weekly. Clients see psychiatrist monthly; individual therapy is weekly. Clinic census: 642 (OMH program) Clinic census: 642 (OMH program)

5. Engagement and Communication With prescribers With prescribers Medical Director or QI point met with psychiatrists. Medical Director or QI point met with psychiatrists. Psychiatrists were receptive to information about improving prescribing practices. Psychiatrists were receptive to information about improving prescribing practices. Reviewed both polypharmacy and cardiometabolic; chose cardiometabolic. Reviewed both polypharmacy and cardiometabolic; chose cardiometabolic. With leadership With leadership QI point reports to the Board of Directors. QI point reports to the Board of Directors.

6. Project Structure Identification of positive cases Identification of positive cases PSYCKES reports were printed by the QI point. PSYCKES reports were printed by the QI point. A memo and form were placed in the clients chart to be completed by psychiatrist every time a case was identified. A memo and form were placed in the clients chart to be completed by psychiatrist every time a case was identified. Clinical review and medication change Clinical review and medication change Psychiatrist would discuss options with client. Psychiatrist would discuss options with client. If switching, psychiatrist would begin a cross-taper. If switching, psychiatrist would begin a cross-taper. Clients would be seen bi-weekly (when indicated) during the cross-taper. Clients would be seen bi-weekly (when indicated) during the cross-taper.

7. Project Structure (cont.) Tracking and follow-up Tracking and follow-up QI point would pull chart after a visit to see completed form. QI point would pull chart after a visit to see completed form. QI point reviewed all positive cases with Medical Director at the end of each month. QI point reviewed all positive cases with Medical Director at the end of each month.

8. Tools- Memo to Prescribers

9. Tools- Review form for Prescribers

10. Integration into Workflow Therapists were aware of project; knew to look for signs of relapse. Therapists were aware of project; knew to look for signs of relapse. CQI project was reviewed in supervision meetings. CQI project was reviewed in supervision meetings. Therapists read psychiatrist notes; psychiatrists read therapist notes as well. Therapists read psychiatrist notes; psychiatrists read therapist notes as well. Therapists alert psychiatrist to significant clinical changes via an "alert" form. Therapists alert psychiatrist to significant clinical changes via an "alert" form.

11. Summary All positive cases were reviewed All positive cases were reviewed Cross-taper is an effective method for switching medications Cross-taper is an effective method for switching medications Well-received by clients Well-received by clients Ongoing monitoring of high-risk patients Ongoing monitoring of high-risk patients Involved team approach with therapists Involved team approach with therapists Active follow-up for no-shows Active follow-up for no-shows

12. Next Steps Screen for positive cases on intake Screen for positive cases on intake Expand to OASAS program Expand to OASAS program Expand to non-Medicaid recipients Expand to non-Medicaid recipients

13. Federation of Organizations QI point: Lisa Weiss, LMSW Corporate Compliance Officer and Director of Quality Management Project: Polypharmacy

14. Clinic Structure Clinic is located within an adult home. Clinic is located within an adult home. Clinic Prescriber: 1 psychiatrist, averages 7 hours per week. Clinic Prescriber: 1 psychiatrist, averages 7 hours per week. Clients see psychiatrist once every 4-8 weeks (every 6 weeks on average). Clients see psychiatrist once every 4-8 weeks (every 6 weeks on average). Social Workers and RNs facilitate group therapy Social Workers and RNs facilitate group therapy Clinic census: varies between 96-100 Clinic census: varies between 96-100

15. Engagement and Communication With prescribers With prescribers Polypharmacy project was chosen during a collaborative meeting with the QI point, Chief Medical Officer (CMO), and psychiatrist. Polypharmacy project was chosen during a collaborative meeting with the QI point, Chief Medical Officer (CMO), and psychiatrist. Prescriber has attended CQI Committee meetings Prescriber has attended CQI Committee meetings With leadership With leadership QI point had support of CMO, CEO, COO. QI point had support of CMO, CEO, COO. QI point reports at senior management meetings and executive meetings; submits monthly reports to the Board. QI point reports at senior management meetings and executive meetings; submits monthly reports to the Board. Agenda item at monthly Consumer Advisory Board meetings. Agenda item at monthly Consumer Advisory Board meetings.

16. Engagement and Communication (cont.) With staff With staff Program Manager discusses CQI Project quarterly at Provider Meetings (adult home staff and federation staff). Program Manager discusses CQI Project quarterly at Provider Meetings (adult home staff and federation staff). Regular agenda item at weekly clinic staff meetings. Regular agenda item at weekly clinic staff meetings. Clinical case conferences occur on a weekly basis between prescriber, clinic supervisor, and RN. Clinical case conferences occur on a weekly basis between prescriber, clinic supervisor, and RN. Case management staff also receive notice of medication changes. Case management staff also receive notice of medication changes. With consumers With consumers Bulletin Board posted at clinic with pertinent CQI Project information. Bulletin Board posted at clinic with pertinent CQI Project information.

17. Project Structure Identification of positive cases Identification of positive cases QI point printed reports from PSYCKES for psychiatrist. QI point printed reports from PSYCKES for psychiatrist. QI Team/clerical staff verified data from PSYCKES by creating excel spreadsheet of all clients with their medication by class; updated monthly and distributed to team QI Team/clerical staff verified data from PSYCKES by creating excel spreadsheet of all clients with their medication by class; updated monthly and distributed to team QI Team/clerical staff conducted chart reviews and reviewed medication and progress note documentation. QI Team/clerical staff conducted chart reviews and reviewed medication and progress note documentation. Clinical review Clinical review Psychiatrist and therapist discuss options with the client. Psychiatrist and therapist discuss options with the client. Weekly case conferences between psychiatrist, clinical supervisor, social worker, and RN. Weekly case conferences between psychiatrist, clinical supervisor, social worker, and RN. Psychiatrist documented rationale in the clients chart if determined that polypharmacy is necessary. Psychiatrist documented rationale in the clients chart if determined that polypharmacy is necessary.

18. Project Structure (cont.) Tracking and follow-up Tracking and follow-up QI point reviews positive cases with CMO and psychiatrist on an ongoing basis. QI point reviews positive cases with CMO and psychiatrist on an ongoing basis. CQI Committee meets monthly in person or via conference call and discusses progress and changes in all positive cases. CQI Committee meets monthly in person or via conference call and discusses progress and changes in all positive cases. CMO and QM Department reviews documentation of psychiatrist re: medication changes/rationale for such. CMO and QM Department reviews documentation of psychiatrist re: medication changes/rationale for such. Team members assist prescriber with accessing PSYCKES. Team members assist prescriber with accessing PSYCKES.

19. Integration with Workflow Initially identified positive cases only through PSYCKES; now, identify additional positive cases at intake and at time of service planning. Initially identified positive cases only through PSYCKES; now, identify additional positive cases at intake and at time of service planning. Created a form for case conferences with prompts. Created a form for case conferences with prompts. See slide. See slide. Amended sheets for physicians progress notes with prompts. Amended sheets for physicians progress notes with prompts. See slide. See slide.

20. Tools- Clinical Case Conference Note

21. Tools- Prescriber Progress Note

22. Summary Used a top-down approach for engagement Used a top-down approach for engagement Identified a cohort of positive cases via PSYCKES Identified a cohort of positive cases via PSYCKES Intake and service planning time Intake and service planning time Team effort to review positive cases Team effort to review positive cases Educated CMO who assisted in engaging prescriber Educated CMO who assisted in engaging prescriber Team effort to choose indicator Team effort to choose indicator Team meets monthly; prescriber periodically attends; all members to review PSYCKES data. Team meets monthly; prescriber periodically attends; all members to review PSYCKES data. Clinical case conferences and chart reviews Clinical case conferences and chart reviews Documentation a priority Documentation a priority Developed new forms and tailored existing forms in order to integrate best practices into routine clinic operations Developed new forms and tailored existing forms in order to integrate best practices into routine clinic operations Results Results

23. Next Steps Continue screening for positive cases at intake and service planning Continue screening for positive cases at intake and service planning Continue to enhance communication among staff (prescriber, case managers, QI team, therapists, adult home staff) Continue to enhance communication among staff (prescriber, case managers, QI team, therapists, adult home staff) Consider expanding to other OMH licensed programs Consider expanding to other OMH licensed programs

24. Questions and Answers