Project Option 1.14.2 Implement other evidence‐based project to develop workforce enhancement initiatives to support access to behavioral health providers in underserved markets in an innovative manner not described in the project options above: Provide psychiatric care, counseling, and nursing at UMC through psychiatric liaison service

Unique Project ID: 138951211.1.8

Performing Provider Name/TPI: The El Paso County Hospital District d/b/a/ University Medical Center of El Paso (UMC) / TPI: 138951211

Project Description:

This project will take a multi-faceted approach to increasing and improving behavioral health care to patients at UMC.

One important step in implementing this project is establishing a program to provide inpatient psychiatric care to patients who are awaiting placement at the El Paso Psychiatric Center, including partnering with private psychiatric facilities to accept UMC patients on a limited basis. Additionally, UMC will provide inpatient psychiatric consultative services to hospital inpatients during the treatment of their medical/surgical conditions, and will establish the use of a psychiatric nurse in the hospital setting to serve as a liaison for both nursing and patient issues.

The first part of auditing the effects of this project involves scrutinizing patient demographics; assessing whether patients are known to have psychiatric diagnoses; reviewing time of arrival to inpatient unit, waiting time on unit, duration of contact with patient, and whether the patient was regarded as having an emergency (seen immediately), urgent (seen within one hour), or non-urgent (seen within one day); diagnosis of each referral, and, just as important, potential costs savings due to reduced patient sitter usage and reduced hospital length of stay (LOS) and associated reimbursement. Finally, data will be reviewed and compared in order to determine if the project is having an effect on Emergency Department throughput.

Goals and Relationship to Regional Goals:

Project Goals: Implement a holistic approach to treating inpatients at the hospital, to include their psychiatric/behavioral treatment needs. This will improve stabilization time for patients awaiting transfer to El Paso Psychiatric Center, and will improve early detection of psychiatric issues for medical/surgical inpatients.

This project meets the following regional goals: This project meets the regional goal of enhancing and expanding behavioral health services to increase access as well as provide service alternatives to inappropriate systems of care. This project will meet this goal by establishing an inpatient psychiatric care program, providing inpatient psychiatric consultative services to hospital inpatients, and establishing a psychiatric liaison in the hospital.

Challenges:

UMC will face challenges in hiring and training the requisite staff to provide psychiatric care in an inpatient hospital setting. Another challenge associated with this project is that of coordinating care decisions and treatment plans between medical, surgical, and psychiatric providers, and incorporating psychiatric consultations into the surgical/medical care model.

5-Year Expected Outcome for Provider and Patients:

We expect to see an improvement in the stabilization time and short-term treatment for patients awaiting transfer to El Paso Psychiatric Center, an improvement in the early detection of psychiatric issues for medical/surgical inpatients, and better coordination of providers and patients through a trained psychiatric nurse.

Starting Point/Baseline:

Many patients awaiting transfer from UMC to El Paso Psychiatric Center are in various stages of being suicidal, homicidal, or otherwise incapacitated due to psychiatric/behavioral conditions. It is crucial, both for cost efficiency and overall health outcomes, that patients receive psychiatric treatment while inpatients at UMC. Providing specialized psychiatric care at the hospital will lessen the amount of time it takes for a patient to be stable enough to transfer, and will likely prevent further deterioration while awaiting transfer. Likewise, many medical/surgical inpatients are in need of psychiatric care, and early detection of these treatment needs while the patient is hospitalized will prevent the need for more expensive interventions in the future when the psychiatric condition may be triggered or exacerbated. Currently, UMC does not have adequate specialized staff (including psychiatrists, mid-levels, or psychiatric nurses) available at the hospital to provide these treatments/consultations. The best method to determine the effectiveness of the NLS is to conduct a retrospective cohort review followed by a prospective study. First, the retrospective method will look backwards and examine the relationship between those patients who have documentation indicating a specific factor (psychiatric diagnosis) in relation to a specific outcome. For example, Length of stay, sitter usage and those other factors previously mentioned. Second, the prospective study will observe for outcomes during a predetermined time period and relate the findings to the implementation of the NLS. The prospective study evaluates the effects of the health care intervention, in which cohorts are divided into groups that are exposed to (NLS service) or not exposed to the intervention of interest. In other words, it is an analytic design to determine the relationship between a condition and a characteristic shared by some members of a particular group.

Rationale:

Mental illness and mental problems, including those of people with learning difficulties, occur in patients of all ages and of different racial, religious and cultural backgrounds. Their problems take many different forms, and different patients bring a variety of specialized needs. Often these needs are clinical and medical, but almost always reach into family, social or working life. Broneheim and colleagues (1998) state than in the general medical setting, as many as 30% of patients have a psychiatric disorder. For this reason, it is often very difficult to have the specialty service needed to treat these unique patients, even in teaching hospitals like University Medical Center (UMC), or for non-specialist staff to be in a position to call in the appropriate specialist help. Sharrock and Happell (2002) explain that there is a growing body of evidence to suggest that nurses working in general hospital settings do not generally consider themselves adequately prepared, skilled or experienced to care for patients with mental health problems whether the symptoms are chronic or secondary to an acute illness. For that reason, the services of an inpatient Acute Psychiatric Liaison (APL) nurse are in dire need at UMC. Nurse Liaison Services (NLS) are an essential part of a whole acute service, ready to respond at any time, to draw in the specialist expertise appropriate to the problem and to arrange the necessary collaboration within, between, and beyond hospital the stay. The APL will have an important role in supporting staff nurses and other health care professionals in caring for patients experiencing mental health problems in the non-psychiatric environment.

Many people can develop mental health problems during major changes in physical health which escalate without intervention. Timely preventive measures and health education can reduce demand on services and greatly improve the quality of life for the patient. Many people experience mental health related issues but have limited or no access to services when these problems are related to physical health treated in the general hospital setting. Consultant physicians are not qualified to provide brief interventions and self-help, primary care has limited capacity, and patients are often not ill enough to qualify for secondary mental health services. El Paso, Texas is severely lacking in resources for the treatment of mental health, developmental disability and related mental health conditions. Many psychiatric patients in the El Paso region are unfunded. The establishment of a psychiatric liaison service will improve the health outcomes of people with chronic and major physical health problems by addressing debilitating mental health issues, reduction in re-admission rates to acute inpatient units, and prevention of escalation of mental health illness events.

Project Components:

This project will accomplish the following project component:

Implement other evidence‐based project to develop workforce enhancement initiatives to support access to behavioral health providers in underserved markets in an innovative manner not described in the project options above.

UMC will provide psychiatric services to inpatients and/or arrange for such services to be provided to these patients at another location.

UMC will provide inpatient psychiatric consultative services to hospital inpatients during the treatment of their medical/surgical conditions.

UMC will establish the use of a psychiatric nurse in the hospital setting to serve as a liaison for both nursing and patient issues.

Unique community need identification numbers the project addresses:

CN.2 Secondary and Specialty Care

CN.5 Behavioral Health

How the project represents a new initiative or significantly enhances an existing delivery system reform initiative:

This project will significantly increase the resources available for psychiatric treatment of inpatients at UMC. Rather than treating patients’ medical conditions and psychiatric conditions separately (which most likely leads to sub-par care for one of those conditions), this project will reform the delivery system by allowing UMC inpatients to receive a greater degree of psychiatric care at the same time as they receive the medical care for which they were admitted to the hospital.

Related Category 3 Outcome Measures:

OD-11 Addressing Health Disparities in Minority Populations

IT-11.5 Other Outcome Improvement Target: must be evidence based, appropriate for proposed project, and meet the definition of an outcome measure.

Reasons/rationale for selecting the outcome measures:

This outcome measure was chosen to measure the improvement in patient outcomes for patients receiving the inpatient psychiatric care that will be made available by this project and managed by the psychiatric liaison. UMC believes that this project will result in improved patient outcomes because these patients will be receiving the psychiatric care they need when and where they need it. In DY3, UMC will determine the improvement target quantification.

Relationship to other Projects: This project is one of several UMC projects which aim to improve the quality and scope of inpatient services at UMC, including UMC’s Hospital-Wide Nurse Advice Line project, Quality EMR Databases project, and Specialized Nursing project

Relationship to Other Performing Providers’ Projects and Plan for Learning Collaborative: HCA Las Palmas is developing a Psychiatric Telemedicine program that will expand access to psychiatric care for patients in the El Paso community.

Performing Providers, IGT entities, and the Anchor for Region 15 have held consistent monthly meetings throughout the development of the Waiver. As noted by HHSC and CMS, meeting and discussing Waiver successes and challenges facilitates open communication and collaboration among the Region 15 participants. Meetings, calls, and webinars represent a way to share ideas, experiences, and work together to solve regional healthcare delivery issues and continue to work to address Region 15’s community needs. UMC, as the Region 15 Anchor anticipates continuing to facilitate a monthly meeting, and potentially breaking into workgroup Learning Collaboratives that meet more frequently to address specific DSRIP project areas that are common to Region 15, as determined to be necessary by the Performing Providers and IGT entities. UMC will continue to maintain the Region 15 website, which has updated information from HHSC, regional projects listed by Performing Provider, contact information for each participant, and minutes, notes and slides from each meeting for those parties that were unable to attend in-person.

Region 15 participants look forward to the opportunity to gather annually with Performing Providers and IGT entities state-wide to share experiences and challenges in implementing DSRIP projects, but also recognize the importance of continuing ongoing regional interactions to effectuate change locally. Through the use of both state-wide and regional Learning Collaborative components, Region 15 is confident that it will be successful in improving the local healthcare delivery system for the low-income and indigent population.

Project Valuation

In determining the value of this project, UMC considered the extent to which the provision of inpatient psychiatric services at UMC will address the community needs, the population served, resources and cost necessary to implement the project, and the project’s ability to meet the goals of the Waiver (including supporting the development of a coordinated care delivery system, improving outcomes while containing costs, and improving the healthcare infrastructure). This project will focus on achieving the Waiver goal of improving outcomes while curbing healthcare costs, because psychiatric services will be available under this project to patients when and where they need it, thereby reducing psychiatric complications and reducing the likelihood of readmission. Additionally, providing these services at the appropriate time makes it more likely that a patient’s mental health problems will be addressed before greater complications can develop, leading to better outcomes and less costly treatment.

138951211.1.8	1.14.2	1.14.2	Implement Other Evidence-Based Project
University Medical Center of El Paso	138951211
Related Category 3 Outcome Measure(s): OD - 11	IT-11.6	138951211.3.8	Addressing Health Disparities in Minority Populations
Year 2 (10/1/2012 – 9/30/2013)	Year 3 (10/1/2013 – 9/30/2014)	Year 4 (10/1/2014 – 9/30/2015)	Year 5 (10/1/2015 – 9/30/2016)
Milestone 1 [P-1]: Conduct gap analysis. Metric 1 [P-1.1]: Baseline analysis of behavioral health patient population, which may include elements such as consumer demographics, proximity to sources of specialty care, utilization of Emergency Department , other crisis and inpatient services including state hospital services used by residents of the region, incarceration rates, most common sites of mental health care, most prevalent diagnoses, co‐morbidities; existing provider caseload, provider demographics and other factors of regional significance. Baseline/Goal: Conduct gap analysis. Data Source: HPSA data; provider licensing and enrollment data from state and local sources; claims and encounters from regional and state data sources; provider and consumer survey, interview, and focus group data. Milestone 1 Estimated Incentive Payment: $1,187,993 Milestone 2 [CQI P-7]: Participate in at least bi‐weekly interactions (meetings, conference calls, or webinars) with other providers and the RHP to promote collaborative learning around shared or similar projects. Metric 1 [P-7.2]: Share challenges and solutions successfully during this bi‐weekly interaction. Baseline/Goal: Share challenges and solutions successfully during this bi‐weekly interaction. Data Source: Catalogue of challenges, solutions, tests, and progress shared by the participating provider during each bi‐weekly interaction. Milestone 2 Estimated Incentive Payment: $1,187,992	Milestone 3 [P-4]: Evaluate and continuously improve strategies. Metric 1 [P-4.1]: Project planning and implementation documentation describes plan, do, study, act quality improvement cycles. Baseline/Goal: Develop documentation. Data Source: Project reports including examples of how real‐time data is used for rapid‐cycle improvement to guide continuous quality improvement (i.e. how the project continuously uses data such as weekly-run charts or monthly dashboards to drive improvement). Milestone 3 Estimated Incentive Payment: $1,296,036 Milestone 4 [CQI P-7]: Participate in at least bi‐weekly interactions (meetings, conference calls, or webinars) with other providers and the RHP to promote collaborative learning around shared or similar projects. Metric 1 [P-7.2]: Share challenges and solutions successfully during this bi‐weekly interaction. Baseline/Goal: Share challenges and solutions successfully during this bi‐weekly interaction. Data Source: Catalogue of challenges, solutions, tests, and progress shared by the participating provider during each bi‐weekly interaction. Milestone 4 Estimated Incentive Payment: $1,296,036	Milestone 5 [I-X]: Hospital inpatients with behavioral health issues. Metric 1 [I-X.1]: Percent of hospital inpatients that receive behavioral health specialized services through innovative project intervention (Psychiatric Nurse Liaison). Numerator: Total number of target population receiving specialized behavioral care through innovative project intervention (Psychiatric Nurse Liaison). Denominator: Total number of hospital admissions for medical conditions who also have behavioral health conditions. Baseline/Goal: 10% improvement over DY3 baseline. Data Source: Written plan from Regional Partnerships. Milestone 5 Estimated Incentive Payment: $2,599,607	Milestone 6 [I-X]: Hospital inpatients with behavioral health issues. Metric 1 [I-X.1]: Percent of hospital inpatients that receive behavioral health specialized services through innovative project intervention (Psychiatric Nurse Liaison). Numerator: Total number of target population receiving specialized behavioral care through innovative project intervention (Psychiatric Nurse Liaison). Denominator: Total number of hospital admissions for medical conditions who also have behavioral health conditions. Baseline/Goal: 10% improvement over DY4 baseline. Data Source: Written plan from Regional Partnerships. Milestone 6 Estimated Incentive Payment: $2,147,501
Year 2 Estimated Milestone Bundle Amount: $2,375,985	Year 3 Estimated Milestone Bundle Amount: $2,592,072	Year 4 Estimated Milestone Bundle Amount: $2,599,607	Year 5 Estimated Milestone Bundle Amount: $2,147,501
TOTAL ESTIMATED INCENTIVE PAYMENTS FOR 4-YEAR PERIOD: $9,715,165

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