Joe Avelino RN, BSN, MHSA, CPHQChief Executive OfficerCollege Medical Center

We, the unwilling, led

by the unknowing, are

doing the impossible

for the ungrateful. We

have done so much,

for so long, with so

little, we are now

qualified to do

anything with nothing.

(Mother Teresa)

Objectives

1) Structure & Design

2) Initiating ED Psychiatry Overflow Unit

3) Building a Discharge Waiting Area

4) Key Success Factors for an Access Department

5) Reviewing Your Staffing & Recruitment

6) ED Physician Collaboration with the Hospital

7) Managing the Homeless Population

8) Collaborating an Alliance with Your Local Police

Department

9) Managing the Care of the Med.- Psych Patient

Population

Strategies

Strategy #1

Structure and Design

Strategy #2

ED Psychiatry Overflow Unit

ED Psychiatry Overflow Unit Policy

ED Overflow Unit Form

COLLEGE MEDICAL CENTER

BEHAVIORAL HEALTH UNIT OVERFLOW REPORT

DATE: October 16, 2014

LICENSE BEDS BHU CENSUS OVERFLOW Unit C

157 73 8

NOTE: * This is on a interim basis, staffing is appropriate, nurses assigned are Competent in taking care of the patients and supplies needed are in place.

Strategy #3

Discharge Waiting Area

Discharge Waiting Area

COLLEGE MEDICAL CENTER

MANUAL: Behavioral Health POLICY #: BHU-00-177

SUBJECT: Discharge Waiting Area EFFECTIVE: Draft

APPROVALS: Chief of Psychiatry REVISED:

REVIEWED:

I. Purpose:

To define guidelines for use of the Discharge Waiting Area (DWA).The Discharge Waiting Area (DWA) is intended to provide a safe, private, relaxing environment for patients leaving the hospital that are waiting for transportation to go to their community setting, discharge designation. The DWA was designed to accommodate prompt patient discharge from the acute behavioral health unit once they have been cleared for discharge and to open up bed availability for patients requiring an acute behavioral admission. The DWA is only for patients that will be discharged to the community.

II. Policy

Discharged behavioral health adult patients who have been cleared and processed for discharge and are awaiting rides, will wait in the designated Discharge Waiting Area until their transportation arrives.

Description of the Discharge Waiting Area

Physical Set-up

• Located adjacent to the behavioral health unit • Staffed with a licensed nurse(s) and experienced behavioral health worker(s)

o Staffing ratio 6 patients to 1 nurse and 1 BH worker • Security will perform rounds every 30 minutes • The location is manned with phone access and security cameras

Comfort

• Recliners • Bathroom • Televisions • Meals • Beverages • Reading materials

Discharge Waiting Area P&P

Pt. Last Name, First

DWA

Arrival

Time

D/C Staff

Name

D/C

Staff

Phone

Ext.

Pt.

Pick-

up

Time

Trans

Type car

taxi

ambulance

other

Trans.

Contact

Name

Trans.

Contact

#

Patient

Pick-up

Time

Pt. given

meds &

Belonging

Discharge Waiting Area Log

Giving Back

I've come to believe that

each of us has a personal

calling that is as unique as a

fingerprint—and the best

way to succeed is to

discover your passion and

then find a way to serve

others.

(Oprah Winfrey)

Strategy #4

Access Services

Scope of Service

Access Services The Access Services Department is open 24 hours a day, seven days a week. It is located on 1725 Pacific Avenue; Long Beach, CA 90806 (South Campus). The department consists of 12 work stations, ambulance dispatch area, employee break area, Access Director Office, and Access Coordinator Office. Access Services averages approximately 1,000 calls a month with over 300 inpatient admissions a month along with over 200 declined admissions (i.e., no bed availability). The most common diagnoses include schizophrenia, psychosis, and bipolar disorders. The Access Department is staffed with Intake Specialists, who are supportive staff, with a minimum of three years’ experience in Patient Access or Access Services. The skill mix and competency of the Intake Specialist includes, but not limited to, insurance verification, financial counselor, and patient access representative. Access Services provides services for inpatient adult and geriatric patients from eighteen and above.

The Scopes of Services offered include:

• Coordinate admissions for Behavioral Health Services from other hospitals, nursing homes,

emergency departments, and acute care services;

• Facilitates transportation of patients for admission from other facilities and our Emergency

Department;

• Dispatches Psychiatric Evaluation Team (PET Team) to assess psychiatric medical necessity for

admission;

• Verifies financial clearance (i.e., authorization and notification);

• Notifies Orange County ETS (Emergency Treatment Services) of all OC residents into our facility ;

• Collaborates with law enforcement to ensure bed placement;

• Transfers adolescent patients to a facility that provides adolescent inpatient services;

• Informs Department of Mental Health (DMH) of all admissions for LA County residents into our

facility.

College Medical Center of Long Beach

Referral Check off List

Face sheet

Insurance Eligibility

H&P

Labs including pregnancy test

Assessment to include Psych history

Hold if applicable

Medical History

Your Contact Information if our nurse has any questions

Please provide us all the necessary documents on this list at once in order to

avoid delays in the review process by our clinical team.

Fax# (562) 256-8493

Access/Intake (855) 844-8898

Access

Services

Referral

Check-Off

List

Bed

Assignment

Form

Date: Time: From: Ext: To: Ext:

Attending Physician: Code Status: Full unless otherwise stated

DNR or Modified Name:

Gender: F or M Age: Diet:

Allergies:

Isolation: Standard Contact Airborne Droplet

Risks: Fall Seizure Suicide Aspiration Assault

Transfer to unit verified: Y N

Medication Reconciliation Done: Y N

Chief Complaint: __________________________

Patient Diagnosis: __________________________

Past Medical Hx: __________________________

______________________________________________

____________________________

Misc. Amb, Wheelchair, Weakness (L,R Bil)

PERTINENT MEDICATIONS

Given: ___________________________________

Pending: _________________________________

Drips/Current Infusion: _____________________

Last Pain Med: ____________________________

IMAGING

ORDERED DONE

___ CT___________ ___

___ MRI__________ ___

___ XRAY_________ ___

___ Other__________ ___

Labs Sent: ________________________________

Pertinent Lab Results: _______________________

Last Vitals: ____________ IV Access: _________

HR: __________________ SpO2: _____________

BP:___________________ RR: ______________

Temp: ________________ Glucose:___________

Pregnancy Test : Pos, Neg, N/A

NEURO: Alert Oriented: x_________

___ PERRLA MAE

Deficits: _________________________

RENAL: VOIDS Foley DOI:______ Anuric DTV

___ Dialysis Cath Site/Type: ______________

Dialysis Sched: M W F or T TH

Last:____

CARDIO: SR SB ST AFIB/AFLUTTER

OTHER

__ Pulse Present

SKIN: Warm/Dry Intact Diaphoretic

___ Skin Alterations: _________________

Photo: DONE

___Cloth removed and change in hospital gown

PULM: RA NC VENTIMASK NRB

BIPAP

Liters O2: _____________________________

Vent Settings: __________________________

ETT/Trach Size/Position_________________

SAFETY: Belonging Searched/ Secured: Y N

___ Valuable in security: Y N

Home meds in pharmacy or with patient

MISC: Restraints: ____ Chemical/

Physical/Med

___ Sitter: Y N

________Date/Time 5150 GD DTO DTS VOL

GI: Abd: Soft Nontender Tender

Distended

___ NPO PO BM: __________________

NGT/OGT Drainage: _____________

Surgical Patient: _____Per-op Surgical check list

____NPO at least 6 hours

____Consent obtained

____Anesthesia consent obtained

PROCEED WITH TRANSFER WHEN ALL OF THE FOLLOWING HAVE BEEN COMPLETED…

___ Report faxed

___ Receiving RN has confirmed receipt of SBAR report

Signature of transferring RN: ______________________ Print Name__________________________

Date:_______ Time:_____

ER Transfer SBAR Form ICU FAX # 562 4261503 Med Surg Fax # 2N 562 997 2493// 2 W 562-490-9668

Unit B 562 997 2284 Perinatal 562 997 2455BHU: 1 W# 562 997 2519 1 S# 562 997 9859 SC # 5622568445

SBAR

Documentation

Form

Strategy #5

Staffing and Recruitment

Strategy #6

ED Physician Collaboration with the

Hospital

From the

Physician Leadership Institute

We need physicians to lead the

healthcare transformation and not just

be spectators. Physician leadership is

not limited to a specific role, title or

position…it is about physicians

embodying the attitudes, behaviors,

perspectives, professional identity

and competencies of a leader.

By Mo Kasti

CONFIDEN

TIAL

PA

GE

25INSERT HOSPITAL LOGO

2016 Emergency Department Efficiencies: Length of Stay

Psychiatric avg LOS is under 6 hrs while LA County is reported to be 10.5 hrs

CONFIDEN

TIAL

PA

GE

26INSERT HOSPITAL LOGO

2016 Emergency Department Efficiencies: Door to Doctor Times

Avg door to doctor times are under BMK of 30 minutes

CONFIDEN

TIAL

PA

GE

27INSERT HOSPITAL LOGO

Best Practices for Psychiatric Emergencies

• Triage and rapid medical evaluation

• High psychiatric acuity with a low rate of restraints utilized at

Strategy #7

Managing the Behavioral Health

Homeless Population

FIRST ADDENDUM TO

MEDICAL TRANSPORTATION AGREEMENT

BETWEEN

COLLEGE HOSPITAL LONG BEACH

AND

FIRSTMED AMBULANCE SERVICES, INC.

The Medical Transportation Agreement between CHLB, LLC dba College Medical

Center/College Hospital Long Beach (“Hospital”) and FirstMed Ambulance Services, Inc.

(“Provider”) effective ____, shall be amended as follows:

1.5 Ambulance Assignment. Provider shall assign two (2) 2013 Ford E-350

ambulances to service Hospital. The said ambulances shall, at Hospital’s discretion, be

customized with the Hospital’s insignia to promote and identify the Hospital and its services.

Hospital retains the right to have its insignia removed from the ambulances at any time, with or

without cause. To the extent Hospital desires to have its insignia removed from the ambulances,

Hospital will provide written notice to Provider requesting that the insignia be removed. Within

seven (7) days from receipt of the written notice, Provider shall have Hospital’s insignia

removed from all ambulances and Provider shall provide Hospital with confirmation of the same.

1.5(a) Transports to “Patient Safety Zone” The Patient Safety Zone is an area in Los

Angeles that is generally known as “Skid Row” and is more specifically described as the

geographic area encompassed by the Central and Newton Divisions of the Los Angeles Police

Departments, bounded by the Pasadena freeway and the Los Angeles River to the North; by the

Harbor freeway to the West; by the Los Angeles River to the East; and by Florence Avenue to

the South. A map of the Patient Safety Zone is attached hereto and incorporated herein.

It is the practice of the Hospital to not transport patients to the “Patient Safety Zone”

unless certain exceptions exist, such as the patient having a fixed permanent residence in the

Patient Safety Zone; the patient is being discharged to a family member with a fixed permanent

residence in the Patient Safety Zone; or the patient is being transferred to another health care

facility that is located in the Patient Safety Zone.

By executing this Addendum, Provider agrees to abide by and comply with Hospital’s

Best Practices on Psychiatric Homeless Patient Discharge Planning, a copy of which is attached

and incorporated herein. Unless an exception applies, Provider agrees to not transport any of the

Hospital’s patients to the Patient Safety Zone. If Provider is requested to transport a Hospital

patient to the Patient Safety Zone pursuant to one of the exceptions identified above, Provider

agrees to first consult with the Hospital’s Chief Executive Officer and Director of Corporate Risk

Management prior to making the transport.

Provider further agrees to keep all ambulances that contain Hospital’s insignia away from

the Patient Safety Zone unless there is an emergency medical need for the ambulances to be

present in the Patient Safety Zone or Provider is making a permitted transport to the Patient

Safety Zone pursuant to the provisions above.

College Medical Center of Long Beach

HOMELESS PATIENT INFORMED CONSENT DISCHARGE FORM /

PLACEMENT OPTIONS

Patient’s Name: ___________________________ Patient’s ID #: __________________________

PLEASE READ THIS DOCUMENT CAREFULLY. IF YOU CANNOT READ OR DO NOT

UNDERSTAND THIS FORM, PLEASE ASK FOR HELP. YOUR SIGNATURE IS

REQUIRED WHETHER YOU ACCEPT OR REFUSE THE DISCHARGE

RECOMMENDATIONS. YOU WILL BE GIVEN A FULLY COMPLETED AND SIGNED

COPY OF THIS CONSENT FORM.

Patient’s Rights: You, as a patient, have numerous rights guaranteed by law which include the

right to compassionate and respectful care, the right to participate in your care and to ask for and to

be provided with all the information you need to make an informed decision about your care, the

right to request or to refuse appropriate and medically necessary treatment, service or medication as

well as the right to leave the hospital against the advice of members of the medical staff except in

certain situations involving an emergency or legal detention. A disclosure of your rights is attached.

Recommended post-hospital care:

The attached Discharge Plan recommends that you:

Offered Rejected

by staff by patient

□ □ be referred to __________________________ □ Sober Living

□ Shelter

□ □ be transferred to _______________________ □ Skilled Nsg

□ Board & Care

□ Retirement/ Asst. Living

□ □ be transported to ________________________ □ Other

Reasons for Recommendations:

Homeless

Patient

Informed

Consent

Discharge

Form

Shelter Contact Checklist

Document Instructions: Complete this form At the time of discharge, if patient requires

shelter- (1) Provide patient with a copy; (2) Maintain a copy in the medical record; (3)

Send another copy to the Behavioral Health Director.

1.

Patient’s Address/

Location of Preference:

2

Accepting Shelter:

Shelter Name:

Shelter Address:

Shelter Phone #:

Shelter Contact Person:

Date of Contact:

Time of Contact:

3.

Requirements of

Accepting Shelter (i.e.,

waiting in line, specific

time format):

Special Instructions:

4a.

4b.

Patient Agrees to

Shelter:

Patient Declines Shelter:

Patient Signature: Date: _ _

Patient Name (printed):

Patient Signature: Date: _ _

Patient Name (printed):

5.

Responsible Party Approval:

I attest that:

The medical record documents that the patient is cognitively intact and able to negotiate the community.

Responsible Party’s Signature: Date: Print

Name: Comments:

Patient Sticker

Homeless

Patient

Shelter

Contact

Checklist

Strategy #8

Build an

Alliance with

Your Local

Police

Department

Mental Evaluation Team (MET) and

Mobile Response Team (MRT)

The Three

Seasons of Timing

When they heard enough

that they have to;

When they learn enough

that they want to; and

When they receive enough

that they are able to.

By John C. Maxwell

Strategy #9

Care of the Med.- Psych

Patient Population

Medical Psych Patient Transfer ProcessRevised January 11, 2017

House Supervisor notifies

Referring Facility.

Physicians must have a phone conversation for official

acceptance.

Supervisor to continue to process as a direct admit by

getting orders from admitting physician and contacting

admitting.Email Gina, Joe, Ava, Access,

Tammy Jo, Mirna, and

Mike Hartman the disposition of

patient.

To determine need for acute medical or surgical care,

Nursing Supervisor will request a faxed copy of the

prospective patient’s clinicals.

(562)989-4850

Please make sure transferring facility is

aware that if they need to reach the

Nursing Office, and use the Office

extension, to please leave a very

detailed message if they are unable to

reach the Nursing Supervisor directly.

Transferring facility will contact Nursing Office House

Supervisor to indicate that they have a patient with acute

medical or surgical care, and behavioral health needs

Supervisor Direct Line: (562)997-2418

Office Phone: (562)997-2275

Email Gina, Joe, Ava, Jay Ann,

Tammy Jo, Mirna, and Mike

Hartman the information on why

the patient does not need acute

medical care.

If it is during the day, you may also

call Access

855-844-8898

562-256-8350

Does the Physician Accept the patient? No

Access continues to evaluate for potential psych admission since they

are not a medical patient.

Supervisor determines type of Physician needed, (ex:

ortho, surgery) and calls Physician from call panel to

present case regarding need for acute medical care.

Yes

Does the patient appear to need Acute Care?

(Please contact Case Management if you feel there is a

need for InterQual assessment; this may delay the

transfer process)

No

Yes

PET team will be notified to travel to transferring facility

to assess need for placement of a hold.

Transferring Medical/Psych Patients to

College Medical Center

Please contact our House Supervisor at (562)997-2418 or

(562)997-2275

If you do not reach them directly, and instead reach the voicemail, please leave

a detailed message which includes:

✓ Your Name

✓ Your Number (where they can reach you directly at your facility)

✓ The patient’s medical diagnosis

After speaking with our House Supervisor, please fax the following to

(562)989-4850:

☐ Face Sheet ☐ EKGs

☐ History and Physical ☐ X-Rays

☐ Last 24 Hour Vital Signs ☐ Physician Consultations

☐ Last 24 Hour Medication Sheet ☐ Physician Progress Notes

☐ Last 24 Hour Nurses’ Notes ☐ All Lab Work, Including UA/UDS

☐ Any Legal Hold Paperwork (5150, 5250, etc.)

☐ Emergency Department Records

Upon receipt and review of these records, and if there is a bed available, our

House Supervisor will contact you with the name and number of the on-call

physician.

In order to complete this transfer, the College Medical Center (CMC) physician

must accept the patient from your physician.

If the patient is not on a hold, and once they are accepted by CMC, the PET

team will be sent to your facility prior to transfer. Results of PET will not

change acceptance.

Strategy #10

Other Points of Consideration in

Behavioral Health Services

Resolution

of Patient

Grievances

College Medical Center

Complaint Documentation Form

Grievance # 2013-

Name of Complainant:

Ph:

Address:

MR#:

Date Submitted:

____________________________________________________________

Department(s):

Complaint Issues:

Call Log: (3 call attempts to complainant)

Investigation Details: (include details on what specific actions were taken. If

staff was counseled include names and dates)

Action/Resolution:

Complaint

Documentation

Form

Trade Name Product Desc # Doses QuantityCost per

Box Total0 $0.00

Latuda lurasidone 80 mg Tab #100 UD 168 1.68 1,808.23 $3,037.83

Abilify ARIPiprazole 20 mg Tab #100 UD 65 0.65 3,498.65 $2,274.12

Restoril TEMAZepam 30 mg Cap #100 UD 467 15.6 138.00 $2,152.80

Abilify ARIPiprazole 10 mg Tab #100 UD 61 0.61 2,473.92 $1,509.09

Latuda lurasidone 120 mg Tab #30 45 1.5 809.69 $1,214.54

Risperdal Consta risperiDONE 25 mg/2 weeks IM Inj, ER (ea) 4 4 290.50 $1,162.00

Abilify ARIPiprazole 5 mg Tab # 100 45 0.45 2,473.92 $1,113.26

Zyprexa OLANZapine 10 mg IM Inj (ea) 31 31 25.20 $781.20

Seroquel ER QUEtiapine 300 mg oral ER Tab #100 44 0.44 1,735.60 $763.66

Abilify ARIPiprazole 2 mg Tab #30 29 0.97 742.23 $719.96

Latuda lurasidone 40 mg Tab #100 28 0.28 1,808.23 $506.30

Geodon ziprasidone 80 mg Cap #40 92 2.3 183.63 $422.35

Abilify ARIPiprazole 30 mg Tab #100 UD 7 0.07 3,498.65 $244.91

Risperdal risperiDONE 2 mg Tab #100 UD 535.5 5.355 34.14 $182.82

Top Ten Drugs (By Month)

In Behavioral Health Services

SERVICE CHIEF/CLINICAL DIRECTOR AGREEMENT

UTILIZATION REVIEW

THIS SERVICE CHIEF/CLINICAL DIRECTOR AGREEMENT is entered into as of this

1st day of April, 2014, by and between College Hospital, Inc., a California corporation doing

business as College Hospital ("Hospital"), and _________________ ("Service Chief/Clinical

Director/Clinical Director"), with reference to the following facts:

RECITALS

A. Hospital is the operator of an acute psychiatric hospital at Cerritos, California, and

desires to establish and operate a program to provide psychiatric services to patients in need of

acute and/or sub-acute services.

B. Service Chief/Clinical Director is an expert in general psychiatry and wishes to

provide services in his area of expertise to Hospital.

C. The parties desire to enter into this Agreement whereby Service Chief/Clinical

Director shall provide the services described herein to Hospital.

NOW THEREFORE, it is agreed as follows:

I. DUTIES OF SERVICE CHIEF/CLINICAL DIRECTOR

Service Chief/Clinical Director shall:

1.01 Provide clinical supervision and direction of the Utilization Review department on

difficult cases.

1.02 Interact with and give advice to physicians, after reviewing the patient’s chart when

potential for a denial is eminent. Such signs of denial include but are not limited to the

following:

1.02.01 A geriatric patient whose length of stay (LOS) is beyond 7 days.

1.02.02 When Utilization Review informs Service Chief/Clinical Director about specific patients who have reached a baseline for at least 24 to 48 hours

or whose documentation is not descriptive supported by evidence of a

UR Medical

Director to

Address

Denials

PSYCHIATRIC EVALUATION SERVICES AGREEMENT

This Psychiatric Evaluation Services and Transfer Agreement (the “Agreement”) is made and entered into as of October 1, 2013 (the “Effective Date”) by and between College Hospital Long Beach, LLC,, a California corporation, d/b/a College Medical Center (“Facility”), and Little Company of Mary Hospital (“Hospital”).

R E C I T A L S:

A. Hospital operates an acute care hospital located at 4101 Torrance Blvd. in Torrance, California and is in need of psychiatric evaluation services for patients presenting with behavioral health problems (“Hospital Patients”).

B. Facility employs and/or contracts with qualified physicians and registered and/or

certified staff duly licensed in the State of California (“State”) with expertise and experience in providing psychiatric evaluation services for patients with behavioral health problems.

C. Hospital and Facility desire to enter into an agreement under which Facility shall

provide psychiatric evaluation services for all appropriate patients of Hospital and care for those patients who require a psychiatric facility.

NOW THEREFORE, in consideration of the promises and mutual covenants herein set forth, it is agreed as follows:

1. RESPONSIBILITIES OF FACILITY

1.1 Services

1.1.1 Evaluation Services. Facility shall provide psychiatric evaluation and related services for Hospital Patients as described in, and in accordance with, Exhibit A as requested by Hospital pursuant to the order of patient’s attending physician. 1.1.2 Placement of Indigent Patients. For patients who require inpatient psychiatric hospitalization but lack the ability to pay for such services (“Indigent Patient”), Hospital may authorize Facility to arrange, at Hospital’s sole cost, inpatient placement for such Indigent Patients at Facility. Such Indigent Patients must meet the admission criteria as set forth in Exhibit D (“Medical Guidelines for Psychiatric Inpatient Admissions”). Prior to admission of an Indigent Patient pursuant to this Section 1.1.2, Facility and Hospital shall complete an authorization form (“Authorization Form”), a copy of which is attached as Exhibit C.

1.2 Hours of Service. Facility shall be available to provide psychiatric

evaluation and placement services twenty-four (24) hours a day, seven (7) days a week. Facility shall respond to requests to perform emergency psychiatric evaluations with a call back to Hospital within thirty (30) minutes of receiving such a request as in accordance with Exhibit A.

Transfer

Agreement

Form

With

Hospital

Summary

1) Review of ED Patient Flow from an Acute Care vs. Behavioral Health from a Patient Perspective.

2) Review Design Structure to avoid a BH patient from harming self and elopement avoidance

3) Create a ED Psychiatry Overflow Unit

4) Create a Discharge Waiting Area

5) Access Services: Check Off List, Bed Assignment Form, SBAR

6) Reducing Registry and Travel Contracted Staff

7) Creating a Reporting Structure to create a culture of ED Physician Collaboration

8) Homeless Patient: Patient Safety Zone, Informed Consent, Shelter Contact Checklist.

9) Collaborate with Your Local Police Department

10) Evaluate Your Process of Admitting Med.-Psych. Patients

11) Patient Grievances

12) Top 10 Behavioral Health Medications

13) UR Medical Director

14) Transfer Agreement Form With Hospitals

Action Items

Questions?