1. Psychiatric Flow Michael Trangle, MD HealthPartners, Associate Medical Director Behavioral Health January 20, 2015

2. Psychiatric Flow Michael Trangle, MD Associate Medical Director Behavioral Health

3. Early Data Fall 2006 3

4. 3-month study which involved all Mpls/St. Paul Metro hospitals with inpatient psychiatric departments including ED units (ANW, Fairview, HCMC, North Memorial, Regions, St. Josephs, United) Involved leadership from DHS and all 7 metro county social services leaders (Ramsey, Anoka, Hennepin, Scott, Carver, Dakota, Washington). 4

5. E.D. Patients 40-50 patients per month are admitted due to lack of access to less intensive resources – 35.3% due to lack of 24 h/d skilled Medical/Behavioral Nursing services or Intensive Residential Treatment services – 23% due to lack of substance abuse services (detox, wet bed, dry bed, CD program with lodging) – 10% due to lack of access to psychotropic prescriber 5

6. Metro Inpatient Psych Hospital Data 240-250 patients per month have “non-acute” days in the hospital This totals to 2,000-2,100 “non acute” days in the hospital per month 6

7. – 29.6% of the non-acute bed days were associated with unavailable beds at AMRTC – 22.4% of the non-acute bed days were associated with a lack of Intensive Residential Treatment beds. – 15% of the non-acute bed days were related to court delays – 8.5% of the non-acute bed days were attributed to lack of CD programs with lodging, need for a Rule 25 assessment, unavailability of sober beds, and need for detoxification – 8.3% of the non-acute bed days were due to needing 24 hr/day skilled Medical/Behavioral Nursing Services – a combination of open and locked environments 7

8. Anoka Metro Treatment Center (AMTRC) data shows 88 patients/month have “non-acute”days Total “non acute” days average 1,718 bed days/months – About 51% are due to lack of Corporate Foster Care / 24 h/d skilled Behavioral/Medical Services – About 21% are due to lack of 24 h/d IRTS for complex behavioral Needs (difficult MI/CD issues) – About 16% due to lack of housing with services availability – About 6.2% are due to lack of complex Medical/Behavioral services 8

9. Conclusions Approximately 550 patients per year are admitted from our metro EDs unnecessarily Approximately 45,000 bed days per year are filled with patients waiting for intermediate resources to become available If we devote adequate resources to intermediate resources our acute care metro hospitals could potentially treat up to 2,733 more patients per year without adding beds (based upon LOS of 9 days) If we devote adequate resources to intermediate resources ARTC could potentially treat up to 344 more patients per year without adding beds (based upon average LOS of 60 days) 9

10. Our Crisis with psychiatric patients being stuck in EDs awaiting inpatient beds and our shortage of inpatient beds is significantly due to lack of: – Housing with supportive services (ranging from a relatively unskilled person available to talk with and remind patient to take meds up to facilities with more intensive programming and ability to manage meds) – Places for patients with both substance abuse and mental health problems (with various attached services ranging from nothing i.e.. sober house to intensive treatment with lodging) – Inefficiencies built into commitment process – Facilities able to serve patients with both MH and medical needs – Timely access to out patient psychiatry (and other advanced practice providers) 10

11. Study also highlights the lack of communication and coordination between hospitals and community social services Study highlights the need for hospital clinicians and county social service providers to develop a common language, sense of responsibility/liability and jointly create more nuanced services based upon clinical need instead of traditional ways of bundling and paying for services. 11

12. Strategies/Efforts to Improve Outpatient Access DIAMOND/Collaborative Care Integrated Care MHDAP Enhanced Crisis Team ACT Adult Psychiatric Urgent Care Center/MHCA Inpatient Emergency Departments Inpatient Psychiatry – NQA & PADs Commitment Process Collaborative to Improve Commitment Process Regions Efforts Intermediate Resources IRTS/Foster Care/Crisis Beds Partial Hospitalization Transition Efforts BH RARE In-Reach Social Worker 12

13. Enhanced Crisis Stabilization Team and Impact 1.Impact of our Mental Health Drug Assistance Program (MHDAP). MDAP was established in 2008 by the East Metro Mental Health Roundtable to help patients with mental illnesses and substance use disorders who were unable to get necessary psychotropic medications. It covers the cost of medications, co-pays, or deductibles for up 3 months (1 month at a time) AND helps eligible patients actually apply and get on insurance products so they can reliably access meds in the future. Over the years, it has:  Helped 1,404 patients access necessary medications  Spent approximately $207,000 per year  Roughly 15% of patients had insurance  Of the initially uninsured, 72% had insurance (and were able to get meds) when leaving the program  10% of participants needed help with co-pays, deductibles, or Medicare spend-down/gap help 13

14. Hospital Psych17% Hospital Psych4% Hospital Physical4% Hospital Physical2% Homeless14% Homeless4% Employed20% Employed19% In Jail6% In Jail1% In Detox/CD Tx8% In Detox/CD Tx4% Thoughts Harm Self22% Thoughts Harm Self8% Thoughts Harm Others 16% Thoughts Harm Others 3% Access Free Meds23% Access Free Meds100% Missed Meds b/c Funds 58% Missed Meds b/c Funds 20% # Participants 1485 # Participants 368 Prior to Starting MHDAPAt end of MHDAP (60 days later for most patients) 14

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16. 16

17. Adult Psychiatric Urgent Care Satisfaction Survey 17

18. East Metro Emergency Departments 18 5.Total behavioral health patient visits in emergency department: 2010-2013 Hospital20102011201220132014 Regions – ER Crisis Program 6,6646,9037,0347,4827,550 St. Joseph’s1,1191,4631,4241,343- United2,1132,4383,0161065- Combined9,66410,70411,156N/A-

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22. In-Reach Social Worker - Outcomes ReferralsCounty of Residence Regions = 21Ramsey = 23 St. Joes = 2Henn = 1 United = 2 Dakota = 1 Housing At Intake - 40% Homeless or Couch Hopping At Close - 33% Homeless or Couch Hopping Insurance 16% uninsured at intake 5% uninsured at close Medical Provider 72% had medical provider at opening 90% had medical provider at closing Psychiatry 48% had psychiatry at opening 91% had psychiatry at closing ER Visits Total ER Visits 6 months Prior = 306; Avg 12.2 Total ER Visits During In-reach = 95; Avg 3.8 Total ER Visits 6 months post = Data incomplete, but a dramatic reduction for those we were able to track 22

23. Non-Qualified Admissions (NQAs) 23

24. Common Reasons for PADs (Regions, 2014 → → → → → → → 24

25. PADs for BH patients - Regions 25 20092010201120122013Jan-July 2014 Number of PADs111020101743145026751887 Percentage of PADs25%22.9%19.0%15.3%19.9%19.7% Note: This source of hospital data looks at PADs for patients who are insured through a HealthPartners health plan only. This is roughly 13% of Region’s behavioral health inpatient population.

26. 72 Hour Holds from ER Crisis Program to BH Units

27. Commitment Process ← ← ← ← ← ← ← 27

28. Hovander House 28

29. Anoka Metro Regional Treatment Center (AMRTC) 29

30. Reducing Re-Admissions (white Paper) http://www.rarereadmissions.org/resources/mental_health.html 30

31. QUESTIONS 31

32. Upcoming RARE Events…. RARE MH Collaborative Final Learning Day Tuesday February 24, 2015 9:00am – 3:30pm Maplewood Community Center 2100 White Bear Avenue, Maplewood, MN Registration now open! Register here

33. Future webinars… To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Networking Webinars, contact: Kathy Cummings, kcummings@icsi.orgkcummings@icsi.org Jill Kemper, jkemper@icsi.orgjkemper@icsi.org