Transforming Mental Health Care in SW Ontario Mental... · 2015. 9. 7. · Evidence indicates key success factor for client transition and tenure in community is provider collaboration

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

Transforming Mental Health Care in SW Ontario

Maintaining Bed Access in the Midst of Bed Closures and Transfers

May 11, 2013

National Health Leadership Conference


Acknowledgements

• Jill MustinPowell, Clinical Director, Regional Mental Health Care London

• Patty Chapman, Mental Health Lead, Southwest LHIN

Colleagues with input into the presentation


The Journey

This presentation will provide

• Information regarding HSRC directives and how they have been implemented or planned for

• Organizational changes to leadership and processes that occurred that have facilitated the transformation

• LHIN support at the system and hospital level

• Outcomes

• Thank you letter from a Discharged Patient

• Lessons Learned

1997 to 2014 …….


Health Services Restructuring Commission Directives - 1997

• Tier 1 – transfer of governance and management of PPH’s to St. Joseph’s

• Tier 2 – transfer of beds & services to 4 partner hospitals and reduction of 70 beds

• Tier 3 – Investment in community services

London & St Thomas Psychiatric Hospitals and St. Joseph’s Health Care London


Implementing the Directives

• Transfer of management and governance of the London and St. Thomas Psychiatric Hospitals to St. Joseph’s Health Care London in January and February 2001

• Current sites were to close and be replaced by new facilities by December 1999 (156 beds will open in London in the fall of 2014 and 89 beds in St Thomas in June 2013)

• Long term goal for St. Joseph’s was to focus on Specialized (tertiary) MH Care service delivery on IP and OP basis

Tier 1


Getting ready for Tier 2

2002 - SW Mental Health Implementation Task Force

2003 - The first principles including the employee rights to follow work and service recognition were established.

- The first functional plan was submitted to MoHLTC

2004 - Tier 2 Partners met

2005 - Infrastructure Ontario was established and the new Infrastructure Ontario (IO) process was introduced - RMHC in 5 year plan, Tier 2 Partners met 5 times.

2002 to 2005


Getting ready for Tier 2

2006 - Deloitte rightsizing review was completed as well a peer review of St. Joseph’s mental health budget - The MOHLTC Tier 3 Document completed - LHINS were established - Clinical Programs realigned - PSR and Recovery Orientation 2007 – Tier 2 Partners begin construction tenders (GR), planning (WRH), revisions to functional plans (SJHH, St. Joseph’s) and costing (STEGH) - Coordinated Access Team put in place 2008 - The Tier 2 Partners endorsed Program Transfer Methodology 2009 – St. Joseph’s Functional Plan approved - Consultation with Psychiatric Rehabilitation experts

2006 - 2009


Tier 2

• Transfer of 50 beds to Grand River Hospital

• Transfer of 30 inpatients

• Transfer of one Assertive Community Treatment Team and one Transition Team staff and patients

• Transfer of 53 staff, reassignment of 50-60 staff and layoff notices to 9 surplus staff

• 50 beds decommissioned at St. Joseph’s

• Delay in transfer of schedule one work for Cambridge Memorial Hospital

• Delay in transfer of dual diagnosis out- patients

2010


Tier 2

• Transfer of 59 beds to Windsor Regional

• Transfer of 17 IPs

• Transfer of 3 ACT teams and related patients, transfer of dually diagnosed OPs

• Transfer of 48 staff transferred to WRH, reassignment of 50 staff, and

layoff notices to 25 staff

• Decommissioning of 59 beds

• Closure of 21 beds – Phase 1 of 3 Phase plan

• Recovery Milieu project

• Long stay/ALC patient reviews started and Transition team initiated

2011


Tier 2

• Kick off meetings with St. Joseph’s Healthcare Hamilton (SJHH) and St Thomas Elgin General (STEGH)

• Cambridge Memorial takes back its acute care work

• Planning for vocational services and Homes for Special Care begins

• Acute care work for Cambridge Memorial transitioned

• STEGH contingency plan developed in response to renovation delay – was to be in June 2013 – new date September 2013

• Quality & Recovery Council

2012


Tier 2

• STEGH contingency plan implemented – IP unit moved to London and ambulatory to community space – additional support to STEGH emergency room

• Vital Behaviours project

• Transitional Discharge project

• SJHH Transfer completed March 31, 2013

• Grand River Dual Diagnosis OPs transferred

• One staff, one IP and 4 OPs transfer

• 22 beds closed – Phase 2 of 3 phases

• 14 beds decommissioned

2013


Tier 2

• Vocational program to close in June

• Bigger and better vocational program begins by CMHA Elgin and Goodwill in St Thomas

• Southwest Center for Forensic MH Care opens June 19 for patients

• STEGH transfer further delayed to later in the Fall 2013

• Plan for decommissioning of (15 beds) planned for fall of 2013

• Patient Flow Management (Bed Boards)

• Decommissioning of current St. Thomas Psychiatric Hospital

2013 continued


Tier 2

• Close second vocational program

• Complete planning for Homes for Special Care

• Close final 27 beds

• Implement HUGO project

• Move into new London facility

• Decommission current London facility

2014


Building Blocks For Cultural Transformation

Clinical Programs realigned - PSR and Recovery Orientation

• General adult programs and specialty program configuration

• Imbalances of resources and of resources

• Not enough specialty focus on psychotic disorders, and mood disorders

• Eight “new” programs – Psychosis, Mood & Anxiety, Assessment, Dual Diagnosis, Adolescents, Geriatric Psychiatry, Concurrent Disorders, and Forensic Psychiatry – IP and ambulatory including 11 ACT teams, outreach teams etc

Leadership, Processes and Front Line Engagement



Coordinated Access Team

• Put in place in 2007

• One communication point for external referrals

• Reduced waiting time for admission

• Internal process of determining where the bed is

• Anticipating bed pressure points

• System flow – registered OP’s, discharges in last 90 days, relationship with acute care




Consultation with Psychiatric Rehabilitation experts

• In 2009

• Recommended that we work on culture change well before the new facilities

• Recommendations regarding documentation, increasing service to clients regarding physical health, education and employment, strengthening our Patient & Family Councils, eliminating restraint & seclusion, peer support and eliminating barriers between staff & patients




Recovery Milieu project

• Focused on a traditional milieu unit

• Months of planning with lots of front line involvment

• Six month pilot with education

• Results very positive for patients and staff

• Changes sustained over time and during change




Long stay/ALC patient reviews

• Began in February 2011

• Focus on long stay patients (LOS > 365 days)

• Reviews involved CCAC, LTC and MH community agencies

• LHIN response to individual funding needs

• To date 104 discharges of long stay patients

• 7 transfers, 5 deaths and 7 readmits

• 85 long stay patients living successfully in the community




Transition Team

• Multidisciplinary team with physician support

• Put in place to assist in the discharge of long stay patients

• Funded for 2 years

• Bridge the gap between inpatient team and community provider

• Identifying other barriers such as family reluctance around discharge




Vital Behaviours project

• 3 phase quality initiative with formal evaluation

• Focused on 3 vital behaviours thought to be fundamental to creating a recovery oriented approach to care

• Be welcoming

• Ask how can I help

• Assist your patient in accomplishing his/her goals

• In analysis stage with reporting back targeted for September




Transitional Discharge project

• CAHO project with eight other hospitals

• Evidence based model (Forchuk et al)

• Our focus is on the unit with longest stay patients partnered with the Transition Team

• Will incorporate a stronger peer support component

• Began in April 2013




Patient Flow Management (Bed Boards)

• Predictive discharge

• Tracking RAIs, legal form renewals

• Changing clinical practice

• Managing bed access

• Changing LOA practices and Using LOA beds

• Identifying discharge barriers




Implement HUGO project

• Healthcare Undergoing Optimization

• Spring 2014

• Will improve medication administration, physician ordering and associated work flows



LHIN support at the system level

System

• Community capacity assessment

• Funding for identified community service gaps

• Funding for special needs patients

• Oversight of system integration between hospitals and community agencies

• Networks for hospital and community service providers

• Sector leads

A Healthier Tomorrow

Context for Leading Change

An identified South West LHIN priority population is: people living with mental health and/or addiction challenges

Locally: 26 community MH agencies with 177 programs and 9 community Substance Abuse agencies with 48 programs

Integration, quality outcomes, and demonstrating value for money are key LHIN objectives

25


Context for Leading Change (cont.)

September 2011: After robust client needs review process including community partners, Tier 2 client transitions were initiated with community capacity impacts

November 2011: Funding to support enhanced community capacity approved; Community Capacity Report received; report called for service enhancements AND implementation of integration opportunities

December 2011: Implementation recommendations re: Community Capacity Report approved by South West LHIN Board

26


Context for Leading Change (cont.)

Evidence indicates key success factor for client transition and tenure in community is provider collaboration

As a strategy to further investigate the current ALC population and develop solutions and recommendations to address current ALC pressures, the South West LHIN announced the ALC Long Stay Initiative on February 25, 2011. The focus of this study was to:

27


Community Capacity Project - Purpose

To identify priorities for existing service coordination and integration new investments necessary to respond to service pressures

To identify evidence-based or emerging practices for identified service gaps

To build an implementation plan for immediate, short, medium, long term needs that identifies actionable priorities for each geographic area within the South West LHIN (North, Central, South)

To strengthen community-based services for individuals with mental health and/or substance abuse problems

28


Community Capacity Report - Process

April 2011 – Project Initiation

May – Literature Review, Population and Health Status Profile and Analysis of System Pressures

June-August – Stakeholder Consultations

September – Draft recommendations shared with South West Addiction and Mental Health Coalition and South West LHIN

October – 2nd Round of Network Consultations

November – Implementation Strategy Developed, Final Document Accepted by South West LHIN Board of Directors

29


Community Capacity Project – Deliverables

Document system capacity and service pressures in the North, Central and South LHIN planning areas

Create a stronger, better integrated community system

Recommend key areas for implementation:

Tier 2 Divestment

Service Integration

Service Enhancement

Special Priority Populations

30


Tier II Divestment

For all individuals discharged from RMHC as a result of 70-bed closure, the following elements must be in place:

Client transition plan

Client care plan

LHIN allocation re: supportive housing, intensive case management, other supports

Also need to better understand the system impacts of less access to inpatient/ambulatory care

31


Service Enhancements

Foundational elements of a community-based mental health and addiction system:

Accredited agencies Access to addictions treatment Access to psychiatric and medical care ACT teams (or lower cost multi-disciplinary teams that are

functionally equivalent) Case management Coordinated access (intake, referral, wait list management) Crisis response teams Peer support Social rehab

Supportive housing (with a range of housing options)

32


Service Enhancements

Foundational elements of a community-based mental health and addiction system:

Accredited agencies Access to addictions treatment Access to psychiatric and medical care ACT teams (or lower cost multi-disciplinary teams that are

functionally equivalent) Case management Coordinated access (intake, referral, wait list management) Crisis response teams Peer support Social rehab

Supportive housing (with a range of housing options)

33


Outcomes

• Wait Times for Bed Access

• Number of Long Stay Patients Discharged

• Average LOS

• Number of Long Stay Patients still in beds


0

2

4

6

8

10

12

14

16

Q1 2011-

12

Q2

2011-12

Q3

2011-12

Q4

2011-12

Q1

2012-13

Q2

2012-13

Q3

2012-13

Q4

2012-13

Days

Average

Wait Time for Beds


0

10

20

30

40

50

60

70

80

90

Series 1

Number of Long Stay Patients Living Successfully in the Community (minus readmits,

transfers, deaths)


0

100

200

300

400

500

600

700

800

2010-11 2011-12 Q1 2012-13 Q2 2012-13 Q3 2012-13 Q4 2012-13

Days

Days

Average LOS (at Discharge)


0

10

20

30

40

50

60

Q1 2011-

12

Q2 2011-

12

Q3 2011-

12

Q4 2011-

12

Q1 2012-

13

Q2 2012-

13

Q3 2012-

13

Q4

2012-13

IPs

IPs

Number of Long Stay Patients in Beds


MC had been hospitalized for a number of years, and on discharge vowed to not return to a mental health facility as an inpatient. She has successfully transitioned to a supported living environment, with the support of an ACT team. Her physical health has been a challenge as well.

She sent a thank-you note to the Transition Team to acknowledge their support.

“Thank you so much for your kindness all these months. I don’t miss the hospital, and I am happy to be in my own home. I like to be out of hospital, I love my place! I love having a private bathroom. Are you sure I can stay here?”

Thank you letter from a Discharged Patient


Lessons Learned

• In order to maintain access to a decreased number of beds focused attention must be placed on discharge planning for long stay patients

• Discharge planning needs to be very creative and needs to include community partners and the LHIN

• Use of evidence based strategies increases success – Transition Team, TDM, Predictive Discharge

• Patient groups remain that are very challenging to discharge – patients with histories of responsive behaviours, patients with acquired brain injury, patients who smoke and have safety issues and patients with severe developmental delays

• Cultural change has to accompany transformation

Documents

Transforming Mental Health Care in SW Ontario Mental... · 2015. 9. 7. · Evidence indicates key success factor for client transition and tenure in community is provider collaboration