A Collaborative Model for Mental Health Providers

1. A Collaborative Model for Mental Health Providers • June 2014

2. Session Objectives • Understand key factors influencing the continuity of care for behavioral health providers • Describe a model for collaboration between mental health providers • Be able to begin developing a plan for collaboration to provide a coordinated care model for patients

3. Your Facilitator • SUE KOZLOWSKI • Ms. Kozlowski’s first career was in the Clinical Laboratory. She has spent the last 12 years facilitating Lean Six Sigma Process Improvement in all areas of healthcare, and is the co-author of “Value Stream Management for Lean Healthcare.” She has also served as an Examiner for the Michigan Quality Leadership Award (Michigan Baldrige program). • Ms. Kozlowski earned her Master of Science in Administration in Healthcare from Central Michigan University and her Bachelor of Science in Medical Technology from Michigan State University. • She is a Certified Six Sigma Black Belt through the American Society for Quality, and holds a certification in Lean Healthcare from the University of Tennessee. She currently services as Director for Healthcare Consulting at TechSolve, Inc., a not-for-profit lean consulting company.

4. Lean Overview

5. Lean is… …a structured problem-solving approach based on PDCA that harnesses employee knowledge and buy-in to create and sustain an improved process. Driving value-added process activities that creates benefit to the customer of the process Reducing costs by eliminating wasted effort, expense, supplies, and space Doing the right thing…right the first time

6. History of Lean Methodology

7. The Process in Reality…

8. The Process on Paper… Outcome Achieved Every Time!

9. So we become… The Kings and Queens Of Work-Arounds

10. Process: A Lean Perspective • Most processes have a significant amount of waste – in healthcare, as much as 90% • Waste costs money • Eliminate waste to reduce costs

11. Key Lean Principles • Respect for people • Elimination of waste • Continuous incremental improvement “Non-Value-Added” or NVA Activities “Value-Added” or VA Activities

12. Lean for Behavioral Health: Developing a Collaborative Model

13. Rapid Improvement Transformation Case Study Prep Core Core Embed Core Assess Value Stream Mapping and Analysis Engagement Scoping Strategic Alignment Team Definition Steering Committee Lean Training Coaching Mentoring Daily Kaizen Sustainment Rapid Improvement Events Project Improvements • Coaching & Project Support Knowledge Transfer • Value Stream and Key Metrics Tracking

14. Engagement and Alignment • Initiation by rural Ohio hospital leaders • Community benefit • Six-county coverage area • Discussions by organization leaders • Financial pressures • Quality issues • Competitiveness as a barrier to quality of care

15. The Current State The hospital and four behavioral health organizations provide inpatient and outpatient programs; one mental health services board collects data for the state and provides oversight Continuum of care was fractured • Duplicate services provided • Confusion over services provided • Clients “gaming” the system • Market competition

16. Pressures • Recent reimbursement changes • Data reporting requirements for the state – different systems with different data • Service reimbursement changes (for example, intake assessment) • Operational costs • Staffing utilization (Professional and administrative) • No call / no show rate • Quality of care / coordination of care issues • Re-admissions for behavioral health clients

17. Behavioral Medicine Value Streams Ambulatory Schedule Pre-Visit Prep Visit Follow-Up Plan Transition to Next Level of Care Outcome Measures: Access; Length of Visit; Cost Per Visit Treat Transition from OP / other care Admit Assess Discharge Transition to next level of care IP Outcome Measures: Length of Stay; Cost per Case; Readmissions Dispo ED Transition from other care Door Doc Depart Transition to next level of care Outcome Measures: Length of Stay; Cost per Case; Revisits; LWBS

18. Where to Begin? The CEOs of the six organizations took an amazing step: They agreed to work together to solve the problems they were encountering.

19. Team Definition • The CEOs met to discuss the problem. • The CEOs agreed to bring in an experienced facilitator from outside the organizations. • Front-line staff and leaders would form the improvement team. • The CEOs would form the Steering Committee.

20. Lean Assessment • Visits to the six organizations (Jan 2011) • Process observations • Feedback from staff • Available measures or metrics

21. Lean Team Formation • Steering Committee / Charter (June 2011) • Report of Assessment Findings • Problem Statement / Project Objective • Metrics • Dates of activities • Team members • Team education / metrics validation (June 2011)

22. Opportunities • Create a patient-centric model of care • Improve access • Continuity of care • Improve quality of care and reduce costs • Improve operational efficiencies • Reduce no call / no show rates • Understand services and specialties at each site • Create a Quality Council • Collaborative approach

23. Lean Project Activities (Jan-Dec) • Charter meeting, 4 hours (7 members on the Steering Committee) • Team education event (14 members on the Core Team) • Value Stream Analysis • Rapid Improvement Events (5) • Sustainment • Closure / Celebration

24. Lean for Behavioral Health: Alignment and Value Stream Analysis

25. Value Stream Analysis Our project is about helping patients get more efficient quality care. It’s important because there are currently a lot of difficulties for patients in our community. When we’re done, we’d like to see an improved experience for clients and staff. What we’d like to see from you is your assistance in the process, support, and an open mind. --Theresa and Elizabeth

26. SIPOC

27. “Just Do-Its” A B C D E ABC F

28. RIE Topics

29. Team Alignment Tool

30. Lean for Behavioral Health: Rapid Improvement Events

31. RIE #1 • Standardized Forms • Standardized Diagnostic Assessment • Accomplishments • Standardized intake form elements • Electronic version for those sites on an EMR • Agreement to share the initial intake form among the organizations • Communication pathway for sharing / legal approval and clearance

32. RIE #1 – “Aha” Moment • Representatives from each organization listed the services they provide • Inpatient • Day Program • Drug and Alcohol • Adults • Teens / Children • Licensed programs

33. RIE #2 • Standardized Forms, part 2

34. RIE #2, continued • Standardized Forms • Other common forms

35. RIE #3 • Community Collaboration • The six organizations identified over 85 community agencies that interacted • Representatives from 4 agencies were invited in to share information • Hope Court: A counselor and one of her clients courageously shared her story of success • 211: 211 Call Center Manager • NAMI: VP and President shared their goals • Hospital Readmission Initiatives: Director of Quality • Anchor Church, “Second Chance” Ministry: Custodian and group leader

36. RIE #3, continued • Community Services Focus • Youth programs • School-based • Other • Law enforcement • Handling of suspected “behavioral” issues • ED interactions • Communication with primary care-giver

37. RIE #3, continued • From the list of community agencies that had to be brought together to collaborate, an idea was born. “Bridge Builders” is a collaboration of Behavioral Healthcare Professionals acting as a service coordination group. For high-utilization, and frequent-utilization clients, the group would develop patient-focused, coordinated care plans. Family and community support and groups would be incorporated as fully as possible.

38. RIE #3, continued Outcomes would include: • Reduction in hospital admissions and readmissions • Decreased cost of care • Improved treatment outcomes The objective of the Bridge Builders program is to demonstrate that a collaborative effort for the target patient populations will reduce overall costs and improve outcomes.

39. RIE #4 • Access / Transitions of Care • IP to OP • OP to IP • Crisis situations • Medical emergency situations • Timeliness of access from first contact to first therapy

40. RIE #4, continued • Example Work Plan: Crisis vs Emergency

41. RIE #5 • Transportation from two perspectives

42. First contact Schedule Appt • Admin Assessment • Clinical Assessment / Therapy • Check-Out, documentation, Billing • ED Intake & Discharge Communication • Crisis Center Utilization • IOP Intake & Discharge Communication • Admission & Discharge Communication • Law Enforcement • Housing Services • Spiritual Care Community • Transportation • Other Community BH Agencies RIE #5: “Aha Moment” Initial Value Stream:  Extended Value Stream: Other community stakeholders:

43. Sustainment • The team developed this definition for the Quality Council: • “A multi-disciplinary team focused on identifying service gaps, providing direction, and resolving issues related to mental and behavioral health in our community.” • Core Team: • The core team will continue to meet twice each month during sustainment; then once each month.

44. Metrics: Contact to Therapy

45. Metrics: No-Shows

46. Metrics: Time to Physician Appt

48. Metrics: Readmissions

49. Opportunities – Success? • Create a patient-centric model of care • Single point of access • Reduce delays in setting appointments • Create collaborative approach between facilities • Improve quality of care and reduce costs • Standard forms • Standard metrics

50. The Six Organizations • Genesis HealthCare System – Bethesda Hospital • Mental Health and Recovery Services Board • Tompkins Child and Adolescent Services • Muskingum Behavioral Health • Muskingum Valley Health Center • Six County, Inc.