Beyond Beds Crisis Now Business Case National Dialogues NOLA 2017
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New Orleans DIalogues on Behavioral Health conference presentation by David Covington on the Crisis Now Business Case - Beyond Inpatient.
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Beyond Beds Crisis Now Business Case National Dialogues NOLA 2017
- 1. Beyond Inpatient The Business Case for Crisis Now 1 David W. Covington, LPC, MBA CEO & President, RI International
- 4. Dr. Michael Hogan, NYS MH Commissioner (2007-2012) Officer Nick Margiotta, Retired Phoenix PD, CIT International BOD Joy Brunson Nsubuga, RI Crisis Administrator, NC Crisis Center Wendy Martinez Farmer, LPC CEO Behavioral Health Link Dr. Michael Allen, Professor Psychiatry & Emergency Medicine Sarah Blanka, RI Crisis Administrator, Arizona Crisis Center
- 5. The Need For Better Crisis Care
- 6. Psychiatric Boarding Seattle Times (2013): Lack of space forced those involuntarily detained to wait for treatment, on average three days, in chaotic hospital EDs and ill-equipped medical rooms. Frequently parked in hallways or bound to beds, usually given medication but no psychiatric care. Carolinas Healthcare benchmarked boarding times in their EDs in 2015 but has since reduced wait times 50% from the figure cited. Law Enforcement Chappell, D (2013) Policing and the Mentally Ill: International Perspectives. Boca Rotan, FL: CRC Press) Madison, Wisconsin data cited by Ruby Qazilbash, Associate Deputy Director, Bureau of Justice Assistance, August 31, 2017 ISMICC Federal Committee One study found that 1 in 10 calls for service involved a person with a serious mental illness Law Enforcement: ImpactonPublic Safety In Madison, Wisconsin, law enforcement found that behavioral health calls for service take twice as long to resolve (3 hours versus 1.5 hours on average) Disastrous Access to Care Wastes Resources 72 hrs 40 hrs 2-3 hrs Washington State North Carolina Person without SMI In 2014, Washington State Supreme Court ruled the waits unconstitutional. Psychiatric Boarding: Long Hospital EDWaits
- 7. 74% 40% 20% None Visual, Hearing or Ambulatory Disability SMI Half as likely to be employed as other individuals with disabilities Finance: Employment No Disability SMIVisual, Hearing or Ambulatory Disability What are the Current Real Outcomes? Health Life expectancy data WHO and NASMHPD, and Disease Prevalence from World Psychiatry Finance Employment data from American Community Survey and NAMI SMI Community Nation data from World Happiness Report (“Someone to rely on in times of trouble”). SMI data from AZ Health Risk Assessments (“Someone to talk to about problems” and “Someone invites me out for dinner/activity.”) Autonomy “Prevalence of SMI Among Jail Inmates” and “Poverty and Severe Psychiatric Disorder” Life for the nearly 10 million people with SMI in the US has comparable outcomes to the average person in Afghanistan. 98% 90% 57% Iceland USA SMI in USA Afghanistan 55-65% Community: Friends& SocialSupports Loneliness Increases Likelihood of Early Death by 30% 4% 20% % of Population w/ SMI % with SMI in Jail 3-5x increase Poverty, Homelessness & Incarceration Autonomy: MakingOwnLife Decisions 15-20% % of Jail Population w/ SMI 84 79 61 Japan USA Afghanistan SMI in USA 2-3x increase Obesity, Diabetes & Cardiovascular Disease Health: AvgLifeSpan 54-69
- 8. People with SMI Suicide Risk According to the American Association of Suicidology, the 2014 suicide rate for males 65+ was 32 per 100,000, but 51 per 100k for those over 85. In 2010, USA Today reported the US Army suicide rate at 22 per 100,000 but the Fort Hood rate was 47 per 100,000. The Suicide Prevention Resource Center (SPRC) reported Alaskan Native/American Indian males ages 15 to 24 had the highest rate at 28 per 100k. In 2010, USA Today reported those AN living in Alaska had a suicide rate of 42 per 100,000. The SPRC says little can said with certainty about death rates for LGBT youth due to limited data collection. Other research suggests two three times the national rate. In 2008, a UK study by Osborn found the hazard ratio for individuals with SMI, including Schizophrenia, to be nearly 13 times the general population. In 2010, King’s Health Partners found the risk to be 12 times greater during the first year following diagnosis of a serious mental illness. Violence While rare, incidents of individuals with SMI who were untreated being involved in the tragic deaths of others have garnered the attention of our national dialogue. Thousands Die Alone and In Despair Suicide Rate: HazardRatiovs.GeneralPopulation White Males 65+ Veterans/Military Alaskan Natives/ American Indians LGBT Youth In 2013, Virginia State Senator Creigh Deeds told CNN he was alive to work for change in mental health. A week earlier, he was stabbed multiple times by his son, who then died of suicide. This happened hours after a mental health evaluation suggested “Gus” needed more intensive services. Tragically, he was released before the appropriate care could be found. Unspeakable Family Pain: TragicOutcomes
- 9. The Skills For Optimizing a Crisis System
- 11. New Year’s Day, you are taking inventory on a key product and you have the following number remaining on the shelf from December. Which is best? 1m Scenario A 1 Scenario B 0 Scenario C 1
- 13. Average Wave: 9 Waves Were “Average” Lowest Wave: 21% of Average Highest Wave: Nearly 200% of Average
- 15. %
- 16. 3 Models Let’s Build Traditional State Hospital Beds Model #1 Crisis Now Model #2 Crisis Now Model #3
- 17. Action Alliance NSPL Lifeline NASMHPD National Council Arizona AHCCCS
- 18. Traditional Public Inpatient In the First Model, implement the 50 public sector psychiatric inpatient beds per 100,000 population necessary to meet community crisis needs. Model #1
- 19. /100,000
- 20. /100,000 The consensus opinion of an expert panel on psychiatric care estimated the need as around 50 public psychiatric beds per 100,000 population (Treatment Advocacy Center). /100,000
- 21. AnyBigCity, USA Pop. 4m AnyBigCity, USA Pop. 4m
- 23. AnyBigCity, USA Pop. 4m Core Community Crisis Demand/Flow
- 24. AnyBigCity, USA Pop. 4m AnyBigCity, USA Pop. 4m Choke Point
- 25. AnyBigCity, USA Pop. 4m AnyBigCity, USA Pop. 4m Choke Point
- 26. AnyBigCity, USA Pop. 4m Dimensions Risk of Harm Functioning Co-Morbidity Environment Treatment History Engagement
- 36. AnyBigCity, USAAnyBigCity, USA Pop. 4m Inpatient
- 37. AnyBigCity, USAAnyBigCity, USA Pop. 4m Inpatient
- 38. AnyBigCity, USAAnyBigCity, USA Pop. 4m Inpatient
- 39. AnyBigCity, USAAnyBigCity, USA Pop. 4m Inpatient
- 42. Readmission Rate %Bed Capacity ALOS Occupancy % Persons Served Per Month Crisis Now Calculator % Bed Days Per Month
- 44. Level of Care Beds ALOS Occupy % Readmit Rate State Hospital 55 400 95% 0% COE 215 12 95% 15% Med-Psych 46 30 95% 10% Hospital-Based 200 6 95% 15% New Capacity 1484 20 95% 10% AGGREGATE 2000 16 95% 11% AnyBigCity, USA Pop. 4m
- 45. What does it cost per year? AnyBigCity, USA Pop. 4m
- 46. Model #2 Crisis Now In the Second Model, add the principle services of the Crisis Now Continuum: a Crisis Call Center, Mobile Crisis and Crisis Facility Services
- 47. Crisis Call Center Mobile Crisis Crisis Facilities The Crisis Now Continuum Outpatient Inpatient
- 52. Mobile Respite Detox Crisis Hub AnyBigCity, USA Pop. 4m AnyBigCity, USA Pop. 4m Choke Point
- 54. In the Third Model, fully deploy the principle practices of the Crisis Now System and add Crisis Navigator and a 24/7 Outpatient Clinic Model #3 Crisis Now
- 55. Outpatient Inpatient Real Time Data Exchange Meet at Their Location Immediate Police Drop Off The Crisis Now System
- 61. Detox Crisis Mobile Respite 24/7 Hub AnyBigCity, USA Pop. 4m AnyBigCity, USA Pop. 4m Throughput
- 62. MobileMobile Detox Crisis Hub Respite AnyBigCity, USA Pop. 4m Core Community CrisisDemand/Flow *8,232 ED visits, representing 7,409 unique persons
- 65. ❶ ❷ ❸ ❻ ❹ ❺ ❻
- 66. ❶ ❷ ❸ ❻ ❹ ❺ ❻
- 69. Outcomes Of Better Crisis Care
- 70. AnyBigCity, USA Pop. 4m Traditional Public Sector Inpatient Beds Model #1 Crisis Now Model #2 Crisis Now Model #3
- 71. Calculated from BJA presentation at ISMICC (2017), Madison, Wisconsin data Saved hospital EDs $37m in avoided costs/losses Reduced total psychiatric boarding by 45 years Calculated from “Impact of psychiatric patient boarding in EDs” (2012) (Nicks and Manthey) Reduced potential state inpatient spend by $260m Calculated from Arizona data, 2017 The Crisis Now Difference Saved equivalent of 37 FTE police officers In 2016, according to Aetna/Mercy Maricopa, metropolitan area Phoenix law enforcement engaged 22,000 individuals that they transferred directly to crisis facilities and mobile crisis without visiting a hospital emergency department. What difference did it make? Improved Crisis Clinical Fit to Need (CCFN) by 6x Fire savings just starting.
- 74. States Self- Assessment Crisis Now Continuum System Framework 14% 29% 38% 12% 0% Level 1 Level 2 Level 3 Level 4 Level 5
- 77. Q&A Crisis Now: Transforming Services David W. Covington, LPC, MBA CEO & President, RI International
Notas del editor
- Vastly outnumbered. Ill equipped. Foraging for resources. The nation’s hospital emergency rooms are the Alamo of mental health access and care. The battle for recovery is lost when individuals in psychiatric and addiction crisis have no where to turn. According to a recent study of the American College of Emergency Physicians, 8 in 10 ER docs say the mental health system is not working for patients.” This wasn’t what President John F. Kennedy and the architects of the community mental health approach intended. Crisis was one of the five original pillars of the movement, but only in recent years have states, counties and health plans started to invest in these important supports and services.
- I’m not going to present a research model. I’m a clinician with an MBA who has worked many years in managed care. I’m going to present the business case for better crisis. That’s not to say that I’ll give you my guestimates. We’re going to show our math. Think about this a little like the old Jurassic Park movie. I’ve got a strong set of DNA from the Arizona excavation, but it’s got some holes. “That’s where our geneticists take over!” was the line of the mad scientist behind the T-Rex. We have filled the gaps with research findings and data from other large systems.
- Unmet Needs
- Michael Schoenbaum in Schizophrenia Bulletin earlier this year showed that young people aged 16 to 30 experiencing first episode psychosis have a much higher death rate than previously thought. He suggests many of these individuals may not even be included in the data set above, despite mortality rates you’d have to compare with 70 year olds in the general population to see similar patterns. Schoenbaum, M., Sutherland, J., Chappel, A., Azrin, S., Goldstein, A., Rupp, A., Heinssen, R. Twelve-Month Health Care Use and Mortality in Commercially Insured Young People with Incident Psychosis in the United States. Schizophrenia Bulletin, April 6, 2017.
- Incoming Call Center Volume Varies, and Varies Widely. If call volume came into centers like a steady flow of water through a pipe, forecasting would not be necessary and planned resources would be simple. Instead, volumes are more like waves at the beach hitting the shore, and each one is different. Think about 15 minute increments being the waves that roll into the beach at the Georgia Crisis and Access Line (May 4, 2015). Between 8am and 5pm those 28 waves varied from the lowest being about 20% of the average and the highest being nearly 200% of the average. There are also significant variations by day of the week, and season to season.
- There are now readily available and inexpensive workforce management software tools that continuously evaluate historic 15 minute by 15 minute data rates to forecast and predict future volumes.
- We’ve estimated the volume in this AnyBigCity at 99,000 visits, based upon our volume data in the Phoenix area. We’ve also reverse engineered the TAC 50 bed per 100,000 model and believe it maps very closely to our experience.
- The Impact of Psychiatric Patient Boarding in Emergency Departments article from earlier referenced 35% going to inpatient and a cost/loss of $2,264 per person (over the course of an 18 hour average ED wait). 99,000 visits denominator Bureau of Justice Assistance references the Madison, Wisconsin experience that law enforcement contacts with mental health required 3 hours each. We certainly have many reports of law enforcement being asked to spend much more time, but this seems like a reasonable metric.
- There is an assumption among policymakers that psychiatric boarding is the result of a loss of sufficient capacity and there’s a number of beds that would solve the problem. That belies a misunderstanding of the referral patterns and flow that actually occurs.
- 8,232 ED visits but 7,409 unique
- https://www.youtube.com/watch?v=ORq1MkODzQU
- https://www.youtube.com/watch?v=abHz5EazTK8