1. Transforming the Concept,Process & Environment of Jim Taliaferro CMHC Admission & Evaluation Services Unit

2. Introduction The Jim Taliaferro Community Mental Health Center Triage Unit was established in early 1990 and is now referred to locally as the “Admission and Evaluations Services Unit”. This unit provides consumer screening for mental health issues, substance abuse services, and provides timely crisis interventions for all Oklahomans in our nine county catchment area in Southwest Oklahoma. The mission of Admission Services is to complete evaluations for all consumers presenting to JTCMHC to determine a diagnoses and assess the type of service that can be provided by our facility to the consumer. Our Coverage Area CIMARRON TEXAS BEAVER WOODS OTTAWA HARPER OSAGE KAY GRANT NOWATA WASHINGTON CRAIG ALFALFA ELLIS WOODWARD GARFIELD NOBLE DELAWARE MAYES ROGERS MAJOR PAWNEE TULSA PAYNE KINGFISHER DEWEY BLAINE WAGONER CREEK CHEROKEE LOGAN LINCOLN ADAIR ROGER MILLS MUSKOGEE CUSTER OKMULGEE OKLAHOMA SEQUOYAH CANADIAN OKFUSKEE McINTOSH BECKHAM CADDO WASHITA POTTAWATOMIE SEMINOLE HASKELL CLEVELAND HUGHES GRADY KIOWA GREER PITTSBURG McCLAIN LEFLORE LATIMER PONTOTOC HARMON GARVIN COMANCHE JACKSON COAL STEPHENS TILLMAN MURRAY PUSHMATAHA JOHNSTON ATOKA CARTER COTTON JEFFERSON McCURTAIN CHOCTAW MARSHALL LOVE BRYAN

3. The Challenge During the 2009 fiscal year, a severe shortage of physicians made it necessary to admit all consumers presenting to Inpatient under ED status after 5:00 pm daily, as there was no physician available to evaluate them until the following morning. This, in turn, produced an unacceptable number of admissions with stays of less than 24 hours, bringing down the average length of stay from 4-5 days to just 2 days. Because the timeframe for completing all assessments and the interdisciplinary treatment plan is determined by the average length of stay, when we were surveyed in 2008 by Center for Medicare and Medicaid Services (CMS) we were required by them to change our policy and to complete all assessments and treatment plans in just 48 hours instead of the usual 72. This change made it necessary to have social workers on site 7 days a week, and even so, the 48 hour deadline was not consistently being met, placing our CMS certification in jeopardy. $ 1,000,000 In Funding in Jeopardy No Physician Coverage The initial purpose of this project was to eliminate the need to admit consumers who did not meet ED criteria and hopefully to return to our pre-crisis average length of stay. Cost Overruns Because of Bad ED Admits

4. The Team A team comprised of directors and coordinators was designated by our Facility Executive Director to address these issues and provide an economical solution. Jim Regan Executive Director Mike Strickland, MD Clinical Director Judy Wallace, Process Improvement Victor Wilkerson Inpatient Director Ellie Cruz, RN Director of Nursing Jill Melrose Evaluations Unit Coordinator Randy Kauk Senior Evaluation Specialist

5. Our Goals A team comprised of directors and coordinators was designated by the Facility Executive Director to address these issues and provide an economical solution with the following goals: Reduce crowding, wait times, and the number of patients who leave without being seen Improve the Emergency Detention Admission Process to provide better integration with Law Enforcement Agencies Create a staffing plan that reduces costs and increases coverage during peak hours. Develop call-coverage strategies and closer alignment with key physicians Provide better patient and staff safety while increasing overall program satisfaction Expand and remodel the Evaluation Unit Provide comfort rooms to consumers and law enforcement personnel to make any wait times more tolerable

6. Methods To accomplish the objectives the Facility Executive Director put before the team the PDSA3 (Plan, Do, Study, Act) model was utilized. Admission and length of stay data from the inpatient unit was collected and compiled for a 6 month time frame to establish trends and peak admission times for each day of the week. It became immediately apparent that by eliminating admissions released immediately after evaluation, the average length of stay would return to pre-crisis levels. It was also determined that by locally adjusting staffing level to the unit would save our facility approximately $230,000 in payroll. Additional cost savings would also be realized from the decrease in frivolous admissions thus reducing overall operational cost in our inpatient unit. PDSA3 Model $230k+ in Payroll Saved! Reduced Operating Cost Total CMS Compliance!

7. Methods

8. The Solution The new jimtaliaferrocmhc Admission & evaluation services unit

9. How it works 1. Consumer is transported to our facility. JTCMHC recognizes the importance of mutual respect and cooperation between our staff and law enforcement, and we make every effort to extend our “warm and welcoming” attitude towards our law enforcement officers as well as our consumers. They are made to feel welcome from the moment they drive into our parking lot with their own designated parking spaces “front and center”. The redesign of our Evaluation Services Unit has resulted in a new entrance for law enforcement. The old design made it necessary for the officers to enter with consumers through a side door which opened directly onto the Inpatient Unit.

10. How it works Adding to the sense of home-like tranquility, at the entrance to the Evaluations Unit is a bright and cheery kitchen for preparing coffee, beverages and nourishments for our guests. Proceeding down the hallway just beyond the kitchen are locked cubbies where law enforcement officers can store their guns. Just around the corner and next to the water fountain is an on-site bathroom which eliminates any need for consumers awaiting evaluation to have to leave the Unit until such time as they are admitted or released.

11. How it works 2. They are welcomed to our newly remodeled Admissions & Evaluations Unit On the new Unit, confidentiality is maintained and the consumer does not enter the Inpatient Unit unless admitted. Our new “comfort room” is a welcoming safe haven for consumers as they await evaluation. The pull-out sleeper chairs are stocked with pillows and blankets under the seats and the adjustable lighting creates a warm and relaxing oasis. (Simulated consumer)

12. How it works Law Enforcement & Department of Corrections are WELCOME Here again, we are pampering our law enforcement officers in their own comfort room as they wait for consumers to be evaluated. The room is right next to the consumer’s comfort room and will soon have a one-way observation window on left wall so that the officers can observe their charges. Refreshments are available, as well as reading materials.

13. How it works 3. Consumer is evaluated, and if criteria is met, admitted by friendly and concerned staff. This is one of three triage offices where our evaluations take place and one of our wonderful triage staff. They all take pride in making their offices warm and inviting. (Simulated consumer)

15. Increased ALOS from 2-3 days to 4-5 days

16. Decreased wait time for evaluations

17. Increased consumer satisfaction

18. Improved relations with law enforcement

19. Improved staff morale

20. 27% decrease in < 30 day readmissions$230k+ in Payroll Saved!

21. Costs and Returns

22. On 8/10/2009 we received a call from Jackson County hospital after normal business hours for an evaluation of a 55-year-old woman who had been admitted for uncontrollable blood pressure and low oxygen levels. She had to be constantly monitored at the hospital because of her unstable medical condition. She was complaining of voices telling her to kill herself. Over the course of her hospital stay, her mental state had cleared, but her doctor would not release her without a psychological evaluation. The Evaluation Unit decided to provide the evaluation at our satellite office in Altus with a Licensed Mental Health Professional in Lawton via video conference. This would save the fragile lady with oxygen tanks from making a three hour trip to Lawton in the custody of a police officer. (Law Enforcement was also interested in this solution as it would be saving them time and money.) The woman was evaluated via video conference and was found to no longer have hallucinations or any suicidal intent, nor did she meet criteria for an inpatient admission to our facility. This was our center’s first Psychological Evaluation via video conference. Both the police and the hospital in Altus have asked for a meeting on the new possibility of remote evaluations because of the convenience, cost savings, and reduction in further trauma to their consumers. Success Story Hope

23. Where to from here?

24. Thank You !