Data tracking, standardized tools aid in psychiatric care
Provider cooperation essential, manager says
Health care leaders at Shoal Creek Hospital in Austin, TX, and in the city as a whole are taking steps aimed to make it easier for psychiatric patients to get access to care.
Challenges they face include a lack of readily available psychiatric expertise and communication barriers between caregivers, says Mark Catalano, LCSW, Seton Shoal Creek Hospital's manager of admissions.
Initiatives designed to streamline the process include a mobile assessment team, telecommuting, standardization of tools and data tracking, and enhanced cooperation and communication between psychiatric hospitals and the emergency department clinicians who send them patients, he adds.
A major focus at Seton, Catalano says, is on "trying to create windows so that ED physicians and social workers know our capacity, what kind of patient is best for us, and which patients go on which unit." It's crucial not only to let them know what's available, he points out, but to realize that each facility has its own way of describing patients.
Seton Shoal Creek uses a standardized risk assessment tool on every patient, including those in inpatient units, Catalano notes. "What we need from the ED [caregiver] is how high the risk is for that patient."
The number derived from the assessment determines whether and where the patient will be placed at the facility, he adds, but often the ED clinician is "not speaking the same language" as staff at the psychiatric facility during the assessment process.
In many cases, Catalano says, the patient in question has been to Seton Shoal Creek before. "We may have seen the patient 10 times, but he or she is new to ED staff and they describe the patient in a way that conflicts with our experience."
A behavioral health patient who presents at the ED "may be at the baseline for him or her," he adds, "but the ED [care provider] thinks the person is out of control." With accurate communication, Catalano says, "we may be able to say, 'Oh, that patient is just coming in to get a meal,' and give them suggestions on how to handle the person."
With such issues in mind, Austin's behavioral health leadership is working to standardize the assessment process across the city, Catalano says, "and see if we can agree on a core set of assessment tools, such as CIWA [Clinical Institute Withdrawal Assessment], CINA [Clinical Institute Narcotics Assessment] neither of which is used by any of the EDs and a suicide or homicide/ aggression assessment."
The implementation of such tools, he adds, will require education for ED nurses and social workers.
A pilot program started at Seton in July 2007, Catalano notes, focused on training social workers throughout the hospital network.
"We brought in all of our on-call social workers for the network those who work all night and educated them on our internal assessment forms so they could do our assessment for us," Catalano says.
When presented with data "on forms we recognized and used, with scores we would use internally," he adds, Seton personnel "know we can trust that [information]."
The payoff carries through to the utilization review piece of the process, Catalano notes, "when from the beginning we get good documentation."
Also under way, he says, is development of a software-based database that would allow "all the players the ED, the emergency medical services and the behavioral health hospitals to share information," he says.
That information would be available, for example, when a patient presents to the ED or is en route to the hospital with an overdose, Catalano adds. With standardized data in one system accessible to all, he says, caregivers can check to see if and where appropriate beds are available for the patient.
With initial responders using the standardized screening tool, Catalano says, "Austin's two private psychiatric hospitals could quickly respond to an alert on a patient needing care with, for example, 'We've got a Level 12 bed on this unit, and it looks appropriate.'
"What EDs want from us is for us to pull patients rather than them having to push them," he points out, "and the more we can trust the form and the language, the more we can do that."
View EDs as customers
In the past, behavioral health providers tended to have an adversarial attitude toward the various EDs in town, Catalano notes. "We realized that we were looking at EDs as the enemy, feeling they were trying to dump patients or not give us all the information and [cases would be] different from what was presented on the phone."
The reality, however, is that the EDs "are our customers the front line that finds patients for us," he says. "We've tried to [shift] our thinking and say, 'What do we need to put in their hands so they are better able to deal with the patient and can become our best sales force?'"
Seton Shoal Creek was on track to develop a mobile assessment team for behavioral health patients, Catalano notes, but it now looks as though the city of Austin with matching in-kind contributions from the hospital networks will take leadership of that project.
The idea, he says, is for caregivers to load information into a city-wide system while observing a patient onsite.
"We're looking at putting together teams in which a social worker and nurse would go out and look at the patient, with one psychiatrist assigned to oversee a certain number [of teams]," Catalano explains. "The psychiatrist would be available to evaluate the individual in person if necessary or could use telecommunication to consult on the case."
Personnel for the mobile assessment team would be hired for the city under the auspices of the state Mental Health Mental Retardation department, he adds. The operation would be tied to the state psychiatric emergency services, Catalano says, "which are the 24-7 gateway to the state [behavioral health] hospital or other services."
At Houston's Memorial Hermann Hospital, where Seton staff made a site visit, a mobile assessment model is in place, he notes. "A medical director is paid to be available and is on call if the nurse or social worker on the team goes out and needs the physician piece."
The psychiatrist participation is "more to help smooth things out with the ED physician if the social worker is recommending something and the ED physician is not in agreement," Catalano says. "The trust factor is a barrier."
Houston is "a year or two ahead on the [telecommuting] curve," he adds. "It's another option for the mobile assessment team if they can't get to the facility across town in a timely fashion. Depending on the level of need, the social worker might do the initial assessment or the physician on call might do it."
In Austin, Catalano continues, there are plans to use mobile assessment in the same way. Returning to the example of a patient in the ED who has been there all night and into midmorning, he says, if such an individual could be interviewed via telemedicine by a psychiatrist or other behavioral health specialist familiar with his or her case, a lengthy stay and possible admission may be avoided.
"This is a way to reach out into the front line and add our level of expertise," Catalano says. "We see these kinds of patients day in and day out."
[Editor's note: Mark Catalano can be reached at [email protected].]
Health care leaders at Shoal Creek Hospital in Austin, TX, and in the city as a whole are taking steps aimed to make it easier for psychiatric patients to get access to care.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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