Strategies for SuccessStrategies for Success

NYSOMH Quality Improvement NYSOMH Quality Improvement InitiativeInitiative

OverviewOverview

Welcome and IntroductionsWelcome and Introductions Agency PresentationsAgency Presentations

Cardiometabolic Risk: Long Island Cardiometabolic Risk: Long Island Consultation CenterConsultation Center

Polypharmacy: Federation of OrganizationsPolypharmacy: Federation of Organizations Questions and AnswersQuestions and Answers

Long Island Consultation Long Island Consultation CenterCenter

QI Point: Elaine LedererQI Point: Elaine LedererExecutive DirectorExecutive Director

Project: Cardiometabolic RiskProject: Cardiometabolic Risk

Clinic StructureClinic Structure

Clinic prescribers: 5 part-time psychiatrists Clinic prescribers: 5 part-time psychiatrists (shared with OASAS program) (shared with OASAS program)

Medical Director oversees psychiatrists, Medical Director oversees psychiatrists, but they do not meet as a team.but they do not meet as a team.

Clients see psychiatrist monthly; individual Clients see psychiatrist monthly; individual therapy is weekly.therapy is weekly.

Clinic census: 642 (OMH program)Clinic census: 642 (OMH program)

Engagement and CommunicationEngagement and Communication

With prescribersWith prescribers Medical Director or QI point met with Medical Director or QI point met with

psychiatrists.psychiatrists. Psychiatrists were receptive to information Psychiatrists were receptive to information

about improving prescribing practices.about improving prescribing practices. Reviewed both polypharmacy and Reviewed both polypharmacy and

cardiometabolic; chose cardiometabolic.cardiometabolic; chose cardiometabolic. With leadershipWith leadership

QI point reports to the Board of Directors.QI point reports to the Board of Directors.

Project StructureProject Structure

Identification of positive casesIdentification 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 client’s chart to A memo and form were placed in the client’s chart to

be completed by psychiatrist every time a case was be completed by psychiatrist every time a case was identified.identified.

Clinical review and medication changeClinical 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) Clients would be seen bi-weekly (when indicated)

during the cross-taper.during the cross-taper.

Project Structure (cont.)Project Structure (cont.)

Tracking and follow-upTracking and follow-up QI point would pull chart after a visit to see QI point would pull chart after a visit to see

completed form.completed form. QI point reviewed all positive cases with QI point reviewed all positive cases with

Medical Director at the end of each month.Medical Director at the end of each month.

Tools- Memo to PrescribersTools- Memo to Prescribers To: All Psychiatrists From: Carl Rosenmann, M.D. Re: LICC Participation in PSYCKES Program LICC is participating in the PSYCKES Program CQI initiative on Cardiometabolic Risk. Basically, patients are identified through Medicaid claims as having been treated for one or several of the following: hypertension, ischemic vascular disease, hyperlipidemia, obesity, diabetes, or prediabetes AND who are taking a moderate to high risk (for these conditions) antipsychotic medication. Our role in this process is simply to try to reduce the risk of cardio metabolic complications by making efforts to get those identified patients off or to reduce the dosage of high-risk drugs. For adults (18 and over) these are olanzapine, quetiapine, chlorpromazine, thioridazine For children/adolescents these are all antipsychotic except aripiprazole and ziprasidone

.

We will have developed a clinical review form that should be completed for each identified patient. Ongoing progress of tapering or rational for not tapering high-risk medications should also be documented on the form. While this will entail additional paperwork, the number of identified patients is small and should not be burdensome. An online educational program is available through PSYCKES about the issues of cardio metabolic risks of antipsychotic use. I encourage each of you to look at this CME program when available.

Attached is a list of your patients that have been identified. Medicaid claim data associated with diagnosis and treatment is in their chart. Please complete the attached form for each client at his or her next appointment.

Tools- Review form for PrescribersTools- Review form for PrescribersCLINICAL NOTES ON PSYCKES STUDY OF HIGH CARDIO METABOLIC RISK

ANTIPSYCHOTIC USE. NAME: _______________________________ AGE: ________________________________ MEDICAL RISK FACTORS (BY DIAGNOSIS TREATED): __________________________________________ __________________________________________ DATE: _____________________________ HIGH/MEDIUM RISK MEDICATION AND DOSAGE: ______________________________________ OTHER MEDICATIONS: _____________________________________ _____________________________________ _____________________________________ HISTORY OF USE OF MED./HIGH RISK MEDICATION (include diagnosis, target symptoms, relevant past history of treatment with antipsychotic/mood stabilizers, efforts to change to alternative lower risk medications)

______________________________________________________________________________

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Integration into WorkflowIntegration into Workflow

Therapists were aware of project; knew to Therapists were aware of project; knew to look for signs of relapse.look for signs of relapse.

CQI project was reviewed in supervision CQI project was reviewed in supervision meetings.meetings.

Therapists read psychiatrist notes; Therapists read psychiatrist notes; psychiatrists read therapist notes as well.psychiatrists read therapist notes as well.

Therapists alert psychiatrist to significant Therapists alert psychiatrist to significant clinical changes via an "alert" form.clinical changes via an "alert" form.

SummarySummary

All positive cases were reviewedAll positive cases were reviewed Cross-taper is an effective method for Cross-taper is an effective method for

switching medicationsswitching medications Well-received by clientsWell-received by clients

Ongoing monitoring of high-risk patientsOngoing monitoring of high-risk patients Involved team approach with therapistsInvolved team approach with therapists Active follow-up for “no-shows”Active follow-up for “no-shows”

Next StepsNext Steps

Screen for positive cases on intakeScreen for positive cases on intake Expand to OASAS programExpand to OASAS program Expand to non-Medicaid recipientsExpand to non-Medicaid recipients

Federation of OrganizationsFederation of Organizations

QI point: Lisa Weiss, LMSWQI point: Lisa Weiss, LMSWCorporate Compliance Officer and Director of Quality Corporate Compliance Officer and Director of Quality

ManagementManagement

Project: PolypharmacyProject: Polypharmacy

Clinic StructureClinic Structure Clinic is located within an adult home.Clinic is located within an adult home. Clinic Prescriber: 1 psychiatrist, averages Clinic Prescriber: 1 psychiatrist, averages

7 hours per week.7 hours per week. Clients see psychiatrist once every 4-8 Clients see psychiatrist once every 4-8

weeks (every 6 weeks on average).weeks (every 6 weeks on average). Social Workers and RN’s facilitate group Social Workers and RN’s facilitate group

therapytherapy Clinic census: varies between 96-100Clinic census: varies between 96-100

Engagement and CommunicationEngagement and Communication

With prescribersWith prescribers Polypharmacy project was chosen during a Polypharmacy project was chosen during a

collaborative meeting with the QI point, Chief Medical collaborative meeting with the QI point, Chief Medical Officer (CMO), and psychiatrist.Officer (CMO), and psychiatrist.

Prescriber has attended CQI Committee meetingsPrescriber has attended CQI Committee meetings

With leadershipWith 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 QI point reports at senior management meetings and

executive meetings; submits monthly reports to the executive meetings; submits monthly reports to the Board.Board.

Agenda item at monthly Consumer Advisory Board Agenda item at monthly Consumer Advisory Board meetings.meetings.

Engagement and Communication Engagement and Communication (cont.)(cont.)

With staffWith staff Program Manager discusses CQI Project quarterly at Program Manager discusses CQI Project quarterly at

Provider Meetings (adult home staff and federation Provider Meetings (adult home staff and federation staff).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 Clinical case conferences occur on a weekly basis

between prescriber, clinic supervisor, and RN. between prescriber, clinic supervisor, and RN. Case management staff also receive notice of Case management staff also receive notice of

medication changes.medication changes. With consumersWith consumers

Bulletin Board posted at clinic with pertinent CQI Bulletin Board posted at clinic with pertinent CQI Project information.Project information.

Project StructureProject Structure

Identification of positive casesIdentification 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 QI Team/clerical staff verified data from PSYCKES by creating

excel spreadsheet of all clients with their medication by class; excel spreadsheet of all clients with their medication by class; updated monthly and distributed to teamupdated monthly and distributed to team

QI Team/clerical staff conducted chart reviews and reviewed QI Team/clerical staff conducted chart reviews and reviewed medication and progress note documentation.medication and progress note documentation.

Clinical reviewClinical review Psychiatrist and therapist discuss options with the client.Psychiatrist and therapist discuss options with the client. Weekly case conferences between psychiatrist, clinical Weekly case conferences between psychiatrist, clinical

supervisor, social worker, and RN. supervisor, social worker, and RN. Psychiatrist documented rationale in the client’s chart if Psychiatrist documented rationale in the client’s chart if

determined that polypharmacy is necessary.determined that polypharmacy is necessary.

Project Structure Project Structure (cont.)(cont.)

Tracking and follow-upTracking and follow-up QI point reviews positive cases with CMO and QI point reviews positive cases with CMO and

psychiatrist on an ongoing basis.psychiatrist on an ongoing basis. CQI Committee meets monthly in person or via CQI Committee meets monthly in person or via

conference call and discusses progress and changes conference call and discusses progress and changes in all positive cases.in all positive cases.

CMO and QM Department reviews documentation of CMO and QM Department reviews documentation of psychiatrist re: medication changes/rationale for such.psychiatrist re: medication changes/rationale for such.

Team members assist prescriber with accessing Team members assist prescriber with accessing PSYCKES.PSYCKES.

Integration with WorkflowIntegration with Workflow

Initially identified positive cases only through Initially identified positive cases only through PSYCKES; now, identify additional positive PSYCKES; now, identify additional positive cases at intake and at time of service planning. cases at intake and at time of service planning.

Created a form for case conferences with Created a form for case conferences with prompts.prompts. See slide.See slide.

Amended sheets for physician’s progress notes Amended sheets for physician’s progress notes with prompts.with prompts. See slide.See slide.

Tools- Clinical Case Conference Tools- Clinical Case Conference NoteNote

CLIENT NAME: (LAST, FIRST M.I.)

AT Activity Therapy HSR Health Screening/Referral PRRD Psych Rehab/Readiness Determination A Assessment MT Medication Therapy SST Support Skill Training CM Case Management ME Medication Education SM Symptom Management CS Clinical Support R Referral TP Treatment Planning CI Crisis Intervention RRD Rehabilitation Readiness VT Verbal Therapy DP Discharge Planning Development

NOTE: Indicate date, service code(s), duration (as appropriate), goal/objective ID for each contact/visit. Include Signature after each progress note.

DATE Service Codes

Duration

Goal/ Obj.

Note:

CS COLL

Client was subject of Case Conference by interdisciplinary treatment team. Attendance: ___________________________________________ ______________________________________________________________________________________________________________________________________________________________________________ Psychiatric Issue(s): i.e. non-compliance with:

Ind VT appointments Grp VT appointments ME/MT appointments Psychotropic Medications other (specify): _____________________ __________________________________________________________ Medical Issue(s): i.e. non-compliance with: Medical appo intments Medical Medications other (specify): __________________________________________________________ Case Management Issue(s): i.e. non-compliance with: Concrete Services (specify): ___________________________________ budgeting (specify): _________________________________________ other (specify): _____________________________________________ __________________________________________________________ Adult Home Issue(s): i.e. related to: HHA Services (specify): _____________________________________ House Cleaning (specify): ____________________________________ financial (specify): __________________________________________ Other (specify): ____________________________________________ Follow-up: _________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________ _________________ __ ____________________ date print signature

BROOKLYN ADULT CARE CENTER CLINIC PROGRESS NOTE

Tools- Prescriber Progress NoteTools- Prescriber Progress Note

CLIENT NAME: (LAST, FIRST)

DATE OF SERVICE:

Current Progress & Mental Status Findings Relevant to Target Symptoms:

Current Suicidal/ Homicidal Risk: Absent Present (describe):

Medication: No t Applicable Client/Responsible Other understands the need for medication Potential Side Effects discussed Previously discussed Side Effects: Absent Present (describe):

Medication Change: No Yes (describe):

Assessment/Plan:

Diagnosis Change: No Yes (describe):

Psychiatrist Signature: Name (print or stamp): Date: Rev’d 6/23/09

BROOKLYN ADULT CARE CLINIC PSYCHIATRIST PROGRESS NOTE

SummarySummary Used a top-down approach for engagement Used a top-down approach for engagement Identified a cohort of positive cases via PSYCKESIdentified a cohort of positive cases via PSYCKES Intake and service planning timeIntake and service planning time Team effort to review positive casesTeam effort to review positive cases Educated CMO who assisted in engaging prescriberEducated CMO who assisted in engaging prescriber Team effort to choose indicatorTeam effort to choose indicator Team meets monthly; prescriber periodically attends; all members Team meets monthly; prescriber periodically attends; all members

to review PSYCKES data.to review PSYCKES data. Clinical case conferences and chart reviewsClinical case conferences and chart reviews Documentation a priorityDocumentation a priority Developed new forms and tailored existing forms in order to Developed new forms and tailored existing forms in order to

integrate best practices into routine clinic operationsintegrate best practices into routine clinic operations ResultsResults

Next StepsNext Steps

Continue screening for positive cases at Continue screening for positive cases at intake and service planningintake and service planning

Continue to enhance communication Continue to enhance communication among staff (prescriber, case managers, among staff (prescriber, case managers, QI team, therapists, adult home staff)QI team, therapists, adult home staff)

Consider expanding to other OMH Consider expanding to other OMH licensed programslicensed programs

Questions and AnswersQuestions and Answers