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Nothing about me without me Nothing about me without me Designing Collaborative Interventions to Reduce Rapid Psychiatric Readmissions: A patient-centered approach to mental health service planning and evaluation. Adrienne Shulman, Patient Support Specialist, Mount Sinai Hospital Rosalie Steinberg, MD, MSc, Psychiatry Resident, U. of Toronto Nadiya Sunderji, MD, FRCPC, Psychiatrist, St. Michael's Hospital

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““Nothing about me without meNothing about me without me”” Designing Collaborative Interventions to Reduce Rapid Psychiatric

Readmissions: A patient-centered approach to mental health service planning and

evaluation.

Adrienne Shulman, Patient Support Specialist, Mount Sinai Hospital

Rosalie Steinberg, MD, MSc, Psychiatry Resident, U. of Toronto

Nadiya Sunderji, MD, FRCPC, Psychiatrist, St. Michael's Hospital

Disclosures/Conflict of InterestDisclosures/Conflict of Interest

None

ObjectivesObjectives

Understand the challenge of rapid psychiatric readmissions and factors associated with readmission causality

Review evidence for collaborative, patient centered approaches that may reduce rapid psychiatric readmissions

Highlight systemic challenges to implementing patient centred mental health care and research

Gain insight, from a patient’s lived experience, into strategies that promote engagement, treatment, acceptance and, ultimately recovery

TerminologyTerminology•

The term “patient”

is used interchangeably with

“end-user, “service user”, “consumer/survivor”, “client”, or “co-researcher”

depending on study

or reference being cited.

Patient experience=lived experience

The Challenge: Rapid ReadmissionsThe Challenge: Rapid Readmissions

Rapid Readmissions = readmissions w/in 30 days of d/c

Likely relapse of single episode vs. recurrence of new episode → partially preventable

Negatively impacts on QOL and Recovery◦

live independently, sense of hope, autonomy, positive self-

identity

“Failure of mental health system to provide cost effective, seamless, efficient and compassionate care for our patients…”

“Perpetuate health inequities, disproportionately affecting marginalized populations who experience greater barriers in navigating and accessing mental health care and other supports after discharge.”

Problem Solving Rapid Psychiatric Readmission at St. Josephs Health Centre, Dr. Nadiya Sunderji

Risk Factors for ReadmissionRisk Factors for Readmission•

SES (unemployment, disability)*•

Dx Schizophrenia* (BAD, Concurrent, Personality Disorder)•

High # of previous admissions or admissions within past yr*•

Impairment of Self Care*•

Medical Comorbidity*•

Decreasing LOS (?Controversial ↑

LOS also cited)*•

Delayed or absent outpatient care*•

Inpatient Psychiatrist caseload (high turnover rate = discharges

per bed/per year)*•

Involuntary admission*

(controversial)•

Low satisfaction with inpatient treatment•

Medication non-adherence

* RF Rapid Readmission

Case: Hospital XCase: Hospital X•

Hospital X has highest psychiatric readmission rate among all Ontario Hospitals

15%

of Ψ

inpatients readmitted to any

hospital within 30

days, 23%

within 90 days

Highest rate of MH&A ED visits of all TCLHIN hospitals

Highest rate of police drop-offs (possible proxy for illness severity)

Economic Burden (approx. $2million/yr) direct care cost

Excludes indirect costs: ED visits, physician compensation, police, ambulance, medical services, readmissions to other hospitals

(ICES) http://publications.cpa-apc.org/browse/documents/602

How to solve the problem: Designing Multimodal How to solve the problem: Designing Multimodal Interventions to Address Underlying CausesInterventions to Address Underlying Causes

Facilitate transitions in care (case managers, aftercare plans)

Increase access to and navigation of outpatient and community-

based resources

Improved QOL and function after discharge from hospital (Increased self care)

Focus on modifiable RFs (medication adherence)

• Enhance our understanding of re-admission causalityKaprow 2007, Dixon 2009, Reynolds, 2004 Forchuck, 2005

Vigod S, Kurdyak P et.al Transitional interventions to reduce early psychiatric readmissions in adults: systematic review, The British Journal of Psychiatry (2013) 202: 187-194

Discordance and Admission causality

> 25% patients explain symptoms other than biologic cause

Side by side comparison of service users and clinicians

Patients: External Stressors ◦

acute crisis, lack of supportive housing, stigma, financial, pressure from family

Clinicians: Individual Deficits◦

‘non-adherence with medication’

Poor impulse control, non-engagement with services.

Attributional differences may explain poor treatment efficacy or why interventions may be more acceptable and effective than others

Mgutshini, T., (2010) Risk factors for psychiatric re-hospitalization: An exploration International Journal of Mental Health Nursing

(19), 257–267

PatientPatient--Provider Discordance Provider Discordance A Matter of PerspectiveA Matter of Perspective

Patients' perspectives on readmission causality have Patients' perspectives on readmission causality have been overlooked: Gap in the Literature been overlooked: Gap in the Literature

Critical oversight in the re-hospitalization research

Medically driven studies

Few Qualitative studies ◦

Attribution Theory (Emic vs Etic)◦

Patient Perspectives on Readmission Causality and Readmission Prevention

Perception that admission is “unjust”

“coercive”◦

Patients’

perceived needs differs from clinicians’

Discordance attribution errors

care plan/treatment

goals are narrowly focused decreased engagement adherence

Sayre, J., The patient's diagnosis: Explanatory models of mental

illness. (2000). Qualitative Health Research, 10(1), 71-83Priebe, et.al. (2009). Patients' views of readmissions 1 year after involuntary hospitalisation. The British Journal of Psychiatry, 194(1), 49-54.

Katsakou, et. Al (2012). Psychiatric patients' views on why their involuntary hospitalisation was right or wrong: a qualitative study. Social Psychiatry and Psychiatric Epidemiology, 47(7), 1169-1179

Brems, C. et. al. (2004) Consumer Perspectives on services needed to prevent psychiatric hospitalization Administration and Policy in Mental Health, 32(1)

You can only design interventions if youYou can only design interventions if you understand the problem. Whatunderstand the problem. What’’s missing?s missing?

“Lack of emphasis on patient centeredness in psychiatry…”◦

one explanation for high rates of treatment non-adherence and dropout among individuals with schizophrenia

“Application of patient-centered care principles within the mental health system has been shown to improve the understanding of provider-intervention-patient interaction,

a missing piece to

designing interventions that are congruent with patients’

beliefs

and preferences about treatment initiation, treatment adherence,

and treatment maintenance.”

Kreyenbuhl, et. al (Jul 2009). Disengagement from mental health treatment among individuals with schizophrenia and strategies for facilitating connections to care: A review of the literature.

Schizophrenia Bulletin, 35(4), 696-703. Barg, et.al. (2010). When late-life depression improves: What do older patients say about their

treatment?.

American Journal of Geriatric Psychiatry, 18(7), 596-605

Definition of Patient and Family Centred CareDefinition of Patient and Family Centred Care

“An approach to planning, delivery and evaluation  of health care that is grounded in mutually 

beneficial partnerships

among patients, families  and health care providers.”

Institute for Patient and Family‐Centered Care

“Providing care that is respectful of and responsive  to individual patient preferences, needs, and 

values, and ensuring that patient values guide all  clinical decisions.”

Institute of Medicine,

Committee on Quality of 

Health Care in America. Crossing the Quality Chasm: A New Health

System for the 21st Century. 

PFCC is guided by four principles:PFCC is guided by four principles:

Three Driving Forces in HealthcareThree Driving Forces in Healthcare

System centred

Patient/Family Focused

Patient/Family Centred

Patient and Family Patient and Family CentredCentred

Driving ForcesDriving Forces

The priorities and choices of patients and families in partnership

with the healthcare team drive the planning,

delivery and evaluation of

healthcare

Patient Family Centred Care involves a new Patient Family Centred Care involves a new way of thinking and workingway of thinking and working

PFCC is a shift from the traditional…

From: What health professionals do to

and for

clients

To: What health professionals do with clients

Implementation of PFCC: WhatImplementation of PFCC: What’’s Required? s Required? A Fundamental Philosophical ShiftA Fundamental Philosophical Shift

→ Strengths→ Collaboration→ Partnership model→ Information sharing→(+) Support→ Flexibility→ Empowerment

DeficitsControlExpert ModelKnowledge (gate-keeping)(-) SupportRigidityDependence

Knowledge is Power. Who is the Expert?Knowledge is Power. Who is the Expert?

What Research shows about Outcomes of PFCCWhat Research shows about Outcomes of PFCC

Improved patient and family outcomes Patients who are active participants in their care experience

better outcomes than those who are not similarly engaged*

Increased patient and family satisfaction

Decreased healthcare costs

More effective use of healthcare resources

Increased professional satisfaction*

Hope and optimism for the future (Shulman)

*2001, Agency for Healthcare Research and Quality (AHRQ) highlighted research supporting active inclusion of patients)

Increased Professional SatisfactionIncreased Professional Satisfaction

Improved Inter-Professional Collaboration◦

Process of communication and decision-making that enables the separate and shared knowledge of health care providers to synergistically influence the patient care provided”

(Way, Jones, Busing 2000)

Improved work satisfaction/quality of work life

Less burnout

Less staff turnover

Patient adherence to treatment plans

New learning for residents and students

Better team functioning and communication◦

? Functioning Team Patient and Family Centred Care Team Functioning?

Implementing PFCCImplementing PFCC Medical College of Georgia Neuroscience CentreMedical College of Georgia Neuroscience Centre

Patient Satisfaction 10th 90th

percentile

Length of stay

50% in Neurosurgery

Staff vacancy rate 7.5% 0% (now a waiting list to work there)

Medication errors

by 62%

Patient complaints

by 67%

Improved perceptions of PFCC

Staff own and protect the new culture

Benefits of Consumer Involvement in Benefits of Consumer Involvement in MH Planning and Service DeliveryMH Planning and Service Delivery

Improved clinical outcomes •

hospitalization, relapse rates and criminal involvement•

Reduction in patient-rated unmet social needs

Promotion of recovery, self-help and fostering of hope •

Consumer involvement predicted improved subjective QOL and functional outcomes

Treatment choice increased adherence to psychiatric treatment

Challenge traditional power differentials •

consumer empowerment leads to better outcomes

Conceptualize service users beyond illness identity

Consumer Involvement Improves Quality, Practice and Consumer Involvement Improves Quality, Practice and Validity of Validity of Mental Health ResearchMental Health Research

Development of congruent research priorities

Recruitment and retention of study participants

Selection appropriate and acceptable outcome measures

Credibility of the research

Individual benefits for consumers/co-researchers

Skill building/empowerment: training in research methodology (demystifying research)

Changing treatment endpoints based on patient preferences

Improved quality of research (data acquisition, interpretation and application of findings etc.)

Carey, Callander, Eisen, Fleming, Fossey, Moltu, Ochocka, Oakley, Thornicraft

Words from our patientsWords from our patients•

“I want you to see me as a human being, not as a diagnosis.”•

“I hear what you are all saying out in the hallway. Why don’t you come into my room and tell me what is going on.”

“I see you writing things down in my chart. How come I can’t see it?”

“My doctor doesn’t hear me.”•

“Why do I have to wear this hospital gown? Who makes up these rules?”

“Last time I saw Dr. X. Now’

it’s Dr. Y. Why can’t I have the

same doctor?.”•

“I’ve already told my story 3 times. Don’t you people talk to each other?”

Barriers to Meaningful Inclusion of Patients Barriers to Meaningful Inclusion of Patients and Familiesand Families

Structural and Attitudinal Barriers: ◦

Financial and human resources

Inadequate training and education (staff and patients)

Lack of incentives (reward or recognition in research)

Hidden curriculum

Primarily Clinician Attitudes◦

Stigma

Tokenism

Service Culture “Culture eats strategy for lunch”

Not Valuing Consumer Participation as Credible

Resistance to Change

Greenall, P. (2006) The barriers to patient-driven treatment in mental health: Why patients may choose to follow their own path, Leadership in Health Services 19

(1). Hall, P. (2005) Interprofessional

teamwork: Professional cultures as barriers. Journal of Interprofessional

Care. 1: 199-196

Role of Patient AdvisorsRole of Patient Advisors--The Lived ExperienceThe Lived Experience

Implementing Advisory role in Mental Health settings

First Do No Harm◦

Avoid Tokenism◦

Accountability with no authority undermining, detrimental

Role Clarity◦

Just having a MH diagnosis doesn’t mean you’re qualified ◦

Can be therapeutic, but do not use as therapy

Lived Experience: How it can influence future readmissions?◦

Discharge Planning◦

Family Meetings◦

Groups

Other creative ways to include patients as partners

Getting Started◦

Send a team to IPFCC◦

Bottom up and top down approachRose, D., (2003b). Having a diagnosis is a qualification for the

job. British Medical Journal, 326, 1331.

Drivers of SuccessDrivers of Success

Engagement of Patients, Families and Communities

Senior Leadership Commitment, Support and Accountability

PFCC Champions

Create a Workplace that Supports Adoption of PFCC

Physician Leads

Education and Training of Healthcare Providers and Students

Integrate PFCC Concepts into Every Policy, Initiative, Program and Research Project

Summary and Take Home Points Summary and Take Home Points

Rapid psychiatric readmissions represent a failure of mental health care coordination and continuity.

Patients' perspectives on readmission causality have been overlooked.

Treatment decisions should be guided by service users’

lived experience.

Patient-centered approaches can address key quality issue and improve inter-professional team functioning.

Summary and Take Home PointsSummary and Take Home Points

Patients' involvement in their own treatment planning decisions are highly correlated with positive mental health outcomes.

Organizational culture and clinician attitudes must be supportive and empowering and avoid tokenism and re-stigmatization.

Eliciting patient perceptions in MH service delivery and research can inform and transform design and evaluation of interventions that are appropriate and effective in reducing rapid psychiatric readmissions.

PFCC is a Journey. PFCC is a Journey. Where do we go from here? Where do we go from here?

“What we call the beginning is often the end. And to make an end is to make a beginning. The end is where we start from.”

T.S. Eliot

Questions and Comments?Questions and Comments?

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