Opening the Doors: A collaborative

Opening the Doors

:

A

collaborative

transition

initiative

to

assist

stable

complex

mental

health

patients

back

to

their

Patient

‐

Centered

Medical

Home

for

mental

health

management

Sarah Willis RN BN

Faculty/Presenter

Disclosure

Presenters:

Sarah

Willis

and

Richard

Alarie

Relationships

with

commercial

interests:

None

to

declare

Acknowledgements:

•

Michelle

Houle

and

Nathan

Turley

Disclosure

of

Commercial

Support

•

This

program

has

received

financial

support

from

Alberta

Health

Services

in

the

form

of

creating

the

new

position

of

Transition

Nurse

at

the

A&MHCC

•

No

specific

initiative

funds,

as

this

initiative

was

supported

through

routine

operational

budgets

at

CFMTC

Mitigating

Potential

Bias

Outline

We’ll

talk

about:

•

Our

two

clinical

groups

•

The

Collaborative

Transition

Project

•

Our

preliminary

findings

University of Calgary ‐ Department of Family Medicine has three Academic 

Teaching Centres:

Academic Teaching Centres are training sites for Physicians and other health 

care providers in family medicine. Learners consist of: • Postgraduate Medical Learners

• Undergraduate Medical Learners

• Clinical Support Team (Nursing and MOA students) • Allied Health Team Members (student Dietician, ...)

Primary Care focus, utilizing the Patient Centered Medical Home Model

Central

Family

Medicine

Teaching

Centre

(CFMTC)

Addiction

and

Mental

Health

Central

Clinic

(A&MHCC)

•

Interdisciplinary

team

concept

(10

clinicians;

7

psychiatrists)

•

Community

Mental

Health

Clinic

system

divided

into

4

quadrants:

•

Target

population

:

adults

with

moderate

to

severe

mental

illness

•

Assessment

and

intervention

with

a

focus

on

recovery

NW _{NE Central} South 

Access

Improvement

Outcomes

at

A&MHCC

2011

‐

review

of

clinic

practices

to

improve

access

(9

month

waitlist)

‐

Online

calendar

system

‐

Centralized

booking

of

intakes

‐

Standard

intake

rate

‐

Treatment

guidelines

‐

Formalized

treatment

reviews

Average wait time Average length of stay

2012‐2013 170 days 361 days

Collaborative

Journey

Through

Mental

Health

Initial

presentation

of

Symptoms

(Primary

Care

Provider)

Acute

Exacerbation

of

Mental

Illness

(Hospitalization)

Symptom

Reduction,

Psychosocial

Set

‐

Up,

Achieving

Wellness

(Mental

Health

Out

‐

Patient

Services)

*Where

the

need

for

this

initiative

exists

Maintaining

Stability

Consultation

‐

Liaison

in

Primary

Care

Program

(CLIPP)

Model developed and evaluated in Australia (Meadows et al, 2007)

Structured approach to collaborative care of people with mental illness 

• Designed to facilitate care management of mental health cases by 

enhancing consultation to specialist mental health programs

Consultation, liaison and education services by psychiatric consultants within primary care practices

Observed outcomes:

Improved capacity to manage mental health issues in primary care

Established transfer process back to primary care from specialist mental 

Creation

of

Primary

Care

Transition

Program

Steps

to

complete:

1.

Create

a

Transition

Nurse

role

2.

Identify

a

pilot

group

of

stable

patients

3.

Create

a

transition

process

Creation

of

Primary

Care

Transition

Program

1. Create a Transition Nurse role (0.5 FTE):

• Work with colleagues to identify transition patients

• Provide care to and monitor patients throughout transition process

• Collaborate with primary care centers to assist in transitioning patients to 

their family physician

• Provide education to primary care staff

Transition process workflow, medications, IM injections, mental 

health, MSE, risk assessment

• Provide support and be available for primary care staff during all stages of 

Creation

of

Primary

Care

Transition

Program

2.

Identify

a

pilot

group

of

stable

patients

–

No

admissions

to

hospital

for

2

years

–

No

significant

adjustments

of

psychiatric

medication

for

1

year

–

Stable

housing

and

established

financial

support

–

Insight

into

need

for

mental

health

treatment

Creation

of

Primary

Care

Transition

Program

3.

Create

a

Transition

Process

–

Creation

of

Primary

Care

Transfer

Summary

–

Initial

meeting

with

patient,

transition

nurse,

and

family

physician.

•

Review

primary

care

transfer

summary

–

Follow

a

pre

‐

determined

transition

schedule

Creation

of

Primary

Care

Transition

Program

Relapse

Signature

(Meadows,

2003)

Specific

set

of

symptoms/signs,

often

subtle

and

patient

specific,

which

warn

that

the

patient

is

at

a

high

risk

of

impending

relapse

•

personal

warning

signs

of

decompensation

•

Change

to

baseline

Mental

Status

Exam

•

Indicate

need

for

further

investigation

•

Once

a

relapse

signature

has

been

developed,

the

task

of

Example

of

relapse

signature:

BE

Primary

• Anxiety which interferes with his weekly routine‐ Brad experiences anxiety 

daily but he is able to cope with same and function in his life (socialize, 

attend group outings, attend scheduled appointments). When he is not 

able to cope with his anxiety it is a sign of decompensation.

• Paranoia – Brad experiences paranoia regarding individuals on the bus but 

generally he is able to rationalize same as a symptom of his illness. If he is 

no longer able to recognize this as a symptom then he will not be able to 

use the bus.

Secondary

• Debilitating Paranoia‐ Paranoid about people in general as well as 

government officials • Auditory Hallucinations

• Ideas of Reference (experiencing innocuous events or mere coincidences 

and believing they have strong personal significance)

• Thought insertion (belief that one’s thoughts are placed in one’s head by 

Creation

of

Primary

Care

Transition

Program

4.

Find

Primary

Care

Providers

to

Accept

Transfer

of

Care

–

Consultation

with

existing

Primary

Care

systems

–

Consultation

with

individual

primary

care

providers

Formal

partnership

between

A&MHCC

and

CFMTC

•

Leadership

engagement

between

the

two

clinics

• Why we got engaged with A&MHCC

•

CFMTC

Registered

Nurse

to

assist

process

development

with

Transition

Nurse:

• Facilitated changes into clinical practice at CFMTC • Trained and supported CFMTC clinical support team 

Facilitated

changes

into

clinical

practice

at

CFMTC

Mutual

Goals

•

Assist

stable

complex

mental

health

patients

back

to

Patient

Centered

Medical

Home

for

mental

health

management

•

Improved

access

to

Community

Mental

Health

Services

•

Clear

process

and

criteria

to

assist

in

the

transition

CFMTC’s

Concerns

•

Minimizing

risk

of

patient

decompensating

•

Expanding

specific

capabilities

for

advanced

clinical

practice

within

nursing

•

Having

support

tools

to

maintain

best

practice

in

assessing

mental

health

and

documenting

care

•

Devising

a

care

management

strategy

for

patient’s

that

decompensate

•

CFMTC

capacity

to

meet

new

type

of

demand

and

unpredictable

volume

Facilitated

changes

into

clinical

Collaborative

Training

and

Support

for

CFMTC

Clinic

Support

Team

Professional

development

activities:

• Stigma

of

Mental

Health

• Stable

Complex

Mental

Health

Patients

(Schizophrenia)

• Mental

Status

Assessment

• Intramuscular

Injection

• Long

Acting

Injectable

Antipsychotics

• Suicide

Prevention

Designed

Workflows

and

Documentation

Templates

Workflows

for

Stable

Complex

Mental

Health

Patients:

• Unattached

patient

find

Primary

Provider

with

Transition

Nurses

support

• Initial

Transition

Appointment

• Ongoing

Mental

Health

Management

(Depot

Injections)

• Stability

changes

within

one

year

Designed

Workflows

and

Documentation

Templates

Custom

Template

Designed

within

the

EMR

(TELUS

Med

‐

Access

EMR)

•

Initial

Transition

Appointment

Initial

Transition

Appointment

Custom

Care

Plan

for

Long

Acting

Injectable

Antipsychotics

 ‐

“Care

Plan

LAI”

•

Monitoring

Task

• for Nurse to monitor patient scheduling & attendance of ongoing 

mental health management appointment 

•

Task

• for Medical Office Assistant (MOA) to add the Primary Care Transition 

Custom

Care

Plan

Continued…

•

Psychiatry:

Profile

Observation

•

Mental

Health

Transition

Summary

•

Mental

Health

Transition

 ‐

Psychiatric

Prescription

•

Goals

of

Care

•

Quarterly:

Blood

Pressure,

Pulse,

Body

Mass

Index,

Weight,

Waist

Circumference

Example of Primary Provider Documentation‐

Setting up Care Plan Goals

Right Click on Clipboard Icon

Click on “LAI” to get the 

care plan goals  for stable 

long acting Injectable 

Example of Primary Provider: Applying Care Plan Goals

Check off Chart Summary

Ongoing

Mental

Health

Management

Appointments

•

Built

in

“Mental

Status

Assessment”

support

tool

to

monitor

for

signs

of

decompensation

Custom Injection Template for Long Acting Injectable 

Antipsychotics:

LAI antipsychotic Injectable Antipsychotic 

Management

plan

if

patient

decompensates

Within

one

year

:

• Notify Transition Nurse

• Patient’s file has not be closed, and can return to A&MHCC for mental 

health management

Beyond

one

year:

• Re‐refer through Access Mental Health • Re‐referral should include:

• Access Mental Health Referral Form 

• A&MHCC Primary Care Transfer Summary  

• Access Mental Health will ensure the patient is booked for “follow‐up” and 

will not be put on the “initial intake waitlist”

If

the

situation

is

considered

an

EMERGENCY

Preliminary

Findings

1

_Patient

_Transition

_was

_June

₁₀

₂₀₁₅

•

7

depot

patients

have

transitioned

since

June

2015=

•

~182

visits

annually

•

4

non

‐

depot

patients

have

transitioned

•

~4

depot

patients

have

been

identified

for

transition

by

Preliminary

Findings

•

Potential

Positive

Impact

on

staff

in

both

clinics:

•

↑ 

Capacity

in

A&MHCC

for

new

pa ents

•

↑ 

Comfort

of

CFMTC

sta

ff 

caring

for

complex

mental

health

patients

•

Potential

Positive

Impact

on

the

patients:

•

↑ 

Rapport

with

CFMTC

sta

ff 

and

Primary

Provider

•

↑ 

Opportunis c

Screenings

•

↓ 

S gma

related

to

needing

specialized

Mental

Health

How

others

can

use

our

experience

•

Recognition

of

potential

modifications

through

collaboration

and

evaluation

•

Value

in

identified

facilitators

•

Transition

Nurse

•

Clinical

Development

Lead

(CFMTC

RN)

•

Application

of

the

Medical

Neighbourhood

principles

does

not

require

all

pillars

to

be

advanced

in

the

Patient

Centered

Medical

Home

(Taylor

et

al,

2011)

References

Meadows, G., Harvey, C., Joubert, L., Barton, D. & Bedi, G. (2007) The 

Consultation‐Liaison in Primary‐Care Psychiatry Program: A structured 

approach to long‐term collaboration. Psychiatric Services, 58(8), 1036‐1038.

Meadows, G. (2003) Overcoming barriers to reintegration of patients with 

schizophrenia: developing a best‐practice model for discharge from specialist 

care. Schizophrenia, 178, S53‐S56

Taylor E.F., Lake T., Nysenbaum J., Peterson G., Meyers D. (2011) Coordinating 

care in the medical neighborhood: critical components and availability 

Thank

you

Questions?