Improving Healthcare Quality: Advanced Clinic Access in Mental Health

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Improving Healthcare Quality Advanced Clinic
Access in Mental Health

• Mary Schohn, Ph.D.
• April 24, 2004

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Background

• Quality of healthcare is determined by the design
  of the healthcare system (Berwick, 2003).
• Three major gaps in the current delivery of
  healthcare are (IOM, 2001)
• Overuse of procedures that do not help people get
  better
• Under use of procedures that can help
• Misuse or errors

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Roadmap to improvement

• Identify gaps between current performance and
  desired performance
• Seek new designs
• Involve everyone (Berwick, 2003)

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VHA/IHI Collaborative

• Started in 1999
• Goals
• Reducing Delays and Wait Times by 50 in six
  pilot clinics
• Redesign clinic scheduling based on model of
  open access
• Spread across all of VHA

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Improvement in Average Next Available Appointment
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Reduction in Wait Times While Patients Increase
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Mental Health and ACA

• Directors Performance Measure FY04
• Added three Mental Health Clinics (502, 509, 510)
  to the ACA Initiative for reducing waiting times
• Directors Performance Monitors FY04
• Number of clinics with wait time greater than 45
  days includes 502,513,531,540 and 547
• Number of patients waiting more than 30 days
  beyond the their desired appointment date.
• Percentage of appointments scheduled as next
  available compared to the national average for
  the MH Performance clinics.
• No show rates

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Current status
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Common Strategies Used in Mental Health ACA in VA

• Match Supply and Demand
• Measure supply and Demand
• Define supply
• Sum of clinic slots
• Based on FTEE assigned to clinic
• Panel sizes
• Define demand
• Sum of consults, walk-ins, calls for
  appointments, rebooks

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Common Strategies used in Mental Health ACA in VA

• Match Supply and Demand
• Reduce appointment types
• Review appointment types to see if efficiencies
  can be gained by eliminating appointment types
  eg. Reduce/eliminate intake appointments
  provider who does initial assessment provides the
  ongoing care 30 minute appointments only triage
  appointment completes the intake appointment.

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Common Strategies used in Mental Health ACA in VA

• Match Supply and Demand
• Plan for contingencies
• Be aware of seasonal variation in demand and
  supply
• Plan for variations develop time off policies to
  ensure coverage cross coverage arrangements

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Common Strategies Used in Mental Health ACA in VA

• Shape the Demand
• Work Down the Backlog
• Hire temporary staff detail staff, use OT
• Review provider schedules
• Reduce other demands on providers time
  temporarily

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Common Strategies used in Mental Health ACA in VA

• Shape the Demand
• Reduce the Demand
• Reduce return rate visits whats the value of
  the next appointment?
• Increase graduation rates
• Develop specialty agreements
• Reduce no-show rate
• Reduce automatic rebooks for no-shows
• Increase group visits
• Make the first visit count

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Common Strategies Used in Mental Health ACA in VA

• Redesign system to increase supply
• Manage the constraint
• Figure out the bottleneck in the process eg. Lack
  of intake slots drop-ins telephone calls
  documentation time

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Common Strategies Used in Mental Health ACA in VA

• Redesign System to Increase Supply
• Optimize the care team
• Review team functions and assignments dont
  have MDs doing work that clerks or nursing staff
  can do eg. AIMS, care coordination, scheduling
  use of dictation
• Redistribute case load to mid-levels

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Common Strategies Used in Mental Health ACA in VA

• Redesign System to increase supply
• Predict and anticipate patient/system needs at
  time of appointment
• Max packing- ensure clinical reminders are done
  at time of visit
• Depression follow-up preset orders

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Common Strategies Used in Mental Health ACA in VA

• Redesign System to Increase Supply
• Synchronize patient, provider and information
• Improve consult requests
• Optimize rooms and equipment
• eg. Telepsychiatry in CBOCs

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Role for Psychology Leaders

• Make it a priority
• Develop Teams
• Review actions
• Aims and goals
• Monthly progress report
• Plans for testing and implementing changes
• Provide for spread activities and opportunities
• Identify opinion leaders

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Role for Psychology leaders

• Empower and Support Champions
• Promote the project
• Publicize team achievements
• Present outcomes at regional/national meetings
• Convert resistance
• Research outcomes
• Become a Clinical Coach

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Resources

• ACA Liaison to MHSHG
• Robert Gresen, Ph.D.
• MH Liasion to ACA Steering Committee
• Mary Schohn, Ph.D.
• ACA website
• http//vaww.vsscportal.med.va.gov/aca/
• ACA MH Monthly Conference Calls

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Resources

• VISN MH POC
• MH ACA Mail group
• MH ACA Satellite Videoconference
• August, 2004