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Summary of Respond We Must! Advancing Quality Improvement in
Behavioral Health Care
Minneapolis, MN. October 27, 2006
Over 100 Mental Health and Substance Use professionals from a cross section of the Minneapolis region, came together to reflect and build will to create a more assertive quality improvement environment to respond to the IOM Report of Crossing the Quality Chasm in Behavioral Health Care. The program was jointly sponsored by many organizations, in itself giving traction to the need and interest in action. Co-Sponsors included HealthPartners, IBHI, MN Dept f Human Services, ICSI, MN Assoc of CMH Programs NAMI, Allina, with speakers also from Blue Cross, and United Behavioral Health Care. Good leadership was apparent at all levels both in organizing the event and especially in Welcome /framing by Mary Brainerd, CEO of HealthPartners and in reflecting by Dick Pettingill of Allina. They “teed” up the issue of a “Hopeful” attitude, “we can make progress,” and practical use of the IOM recommendations as framing elements for action by their systems (and if their systems why not ours?). They encouraged those attending to think outside the box, and practice imagination in designing solutions. There were good examples of ideas that worked from United BHC, HealthPartners and descriptions of issues from the ER to progress in Depression and State initiatives.
The audience and participant list produced a group that can mobilize some constructive action. The afternoon breakouts were productive, energized and listened to by leadership and the collective audience. About 2/3 of attendees stayed for the entire day, a Friday afternoon and that says something good about the attention and interest in the issues. Initial action steps were to have behavioral health care acknowledged as a target for improvement by the Institute for Clinical Improvement Studies (ICIS) and to target ED care as an area for collaborative work.
Early in the agenda the participants heard two strong Patient-case studies in the first or second person. The first, the mother of a Schizophrenic; the other a complex depression/co-morbidity patient . The family’s focus of attention and measure of success ranged from “ How do we keep delusions down to a manageable level so our son can safely live as an outpatient, to “how can we help our son maximize happiness and quality of life”. The patient highlighted his struggles/successes with socializing and his addictions (nicotine and alcohol). He shared the power of thinking and acting about his overall healthcare and not separating Behavioral Health issues from the rest of him. Woven into the tapestries of their lives was the constant endless struggle to get the services/help they need – in a system that consistently fragments and breaks down.
These remarks were straddled by framing references by Mary Brainerd CEO HealthPartners; and Dick Pettingill, CEO from Allina, both left little margin for the scale of the breakdown, and the “chasm”; a community problem that transcends any one system. They offered some strong encouragement to re-design care, apply collaboration as a method, and encouraged us to use our imagination to seek solutions. Dick Pettingill referenced a finding of the 9/11 Report that the tragedy was magnified by Leaderships failure of imagination in planning for a threat. He closed with the advice to seek early wins, and not try to “boil any oceans”
Harold Pincus, MD, followed with a framing presentation, drawn from the IOM studies, his work in Depression and Primary Care and his sense of urgency about what must happen to have patients cared for “between the silos”; and to apply the Chronic Care Model (Ed Wagner) verses the Acute care model to BHC. He personalized his remarks in two slides asking “What does all this mean to you?” which could be a high level assessment reference for any organization contemplating improvement of integration; followed by the rather “bare” outcome data on Depression, ADHD, and Substance Use care, and closed with the call to “build bridges and apply ”Six Critical Pathways for Achieving Aims:”
- New Ways of delivering Care
- Effective use of Information Technology (IT)
- Managing the Clinical Knowledge, skills, and deployment of the workforce
- Effective teams and coordination of Care across patient conditions, services and settings
- Improvement in how quality is measured
- Payment methods conducive to good quality.
Presentations of Early Successes and Challenges
ED Presentation
Highlighted difficulties of patients waiting in EDs for inpatient psychiatric beds to become available, being transferred long distances (tying up scarce ambulance resources), and family hardships involved.
MHAG
Highlighted goals and progress from this high level public/ private consortium - especially:
- Minimum benefit set
- Quality reporting
- Policy recommendations
- DHS strategies
Quality Service Enhancements Presentation
Highlighted success of innovative public private multi-disciplinary crisis team in avoiding hospitalization and enhancing quality of life for patients in St. Louis County.
Depression in Primary Care
Highlighted best practices and progress/ status of ICSI Depression Action Group
- Involves 75% of Primary Care Physicians in Minnesota
- Great progress in appropriately diagnosing and engaging patients/families in their care
- Great progress in documenting symptoms and beginning to measure baseline symptom severity
- Struggling with reliable follow up
- Beginning to get acute and continuing care outcomes data (response and remission rates)
Behavioral Health & Primary Care Integration
Discussed the various models to integrate Behavioral Health and Primary Care ranging from the most integrated of “shared care” along a continuum to purely referral relationships. Highlighted specific Minnesota based initiatives in this area.
Specific Recommendations from the IOM Report: View from the Health Plans
Highlighted the roles available to health plans to facilitate IOM recommendations including decision support, education, consciousness raising, and a stepped approach to case management.
Other hopeful remarks heard along the way
“It’s Health Care…” remark echoed several time over trying to make “general and Behavioral/Substance use care distinct, which defeats the goal of a more integrated System. Of note one of the patient framers described one of his abused substances as nicotine and smoking
“ We’re an unusual audience…We could do something” - Steve Sterner, MD, Hennepin CMC, ER, in reflecting on who was in attendance while giving data of ER Length of stay, care and transfers; (he clearly saw the problem and while he had lobbied for more psych beds, also knew the issues were bigger than that I think) He asked whether we were about replicating more of the old system or redesigning a new?” He described a new psych ER and put some expectation on us noting the “proof would be what happens from here”.
Later in talking about the reality of an urban county hospital; “we’re doing pretty well, I think, although some days we feel good if we catch up to being “one step behind.”
“It (QI) appears simple, but the sometimes it requires an extra click”…Mike Trangle, MD, Health Partners Regent Hospital, He described the use of an extra-step required to make a general verses a specific diagnosis of Depression in an EMG.
“Will you make a follow-up appointment at the desk?” A simple exchange between clinician and patient which had caused an increase in follow-up appointments (also in Mike Trangle’s presentation).
Echoes of “relationships” as key system elements in a re-designed system.
“I was sick and tired of being sick and tired, and I finished reading the letter, and it was signed Kerry, so I called her.” Patient who received a letter from a Health Plan case worker, after a claims review showed high risk of Substance use. The letter engaged the patient in successful treatment.
“Relationship-centered care is more than Patient centered care, it not only puts the patient in the center, it requires awareness of all the elements that support him/her and each other”. – One of the afternoon leader responders
The afternoon charge was to 7 (originally 10) groups in four (4) Topic areas: Depression (3), Schizophrenia, Substance use (2) and ADHD. Who reported out in steps that could be taken over; Heartened by the high energy apparent even in the early afternoon, didn’t catch all the recommendations although one general was to have an email “list serve to keep the conversations going. Among the listening:
- A very interactive conversation on how to improve follow-up rates with Depression patients, “perhaps we should benchmark with Vets and Dentists they seem to know how to do it?
- “It’s rare when sit, talk and reflect in a community of professionals”. Speaks to the value of the breakout session and of the ability of the facilitators to get to the heart of the matter (Although it was too bad in a way we didn’t have an ER care collaborative operational to build on the points made by Steve Sterner).
A few phrases from the afternoon’s reprise:
- “I’m struck by how much we do know, and can spread”: Wes Koostra, in referencing the work done by United BHC and the State of MN
- “We’ve a real opportunity to build some reliability into our system; although we also need for more reliable measurement
- “I’m not a natural optimist, but I’m excited by what I’ve heard”
Michael Trangle MD, introduced the idea of what to do next with two good stories. The first about a resident-mate who’s first post residency position was in a CMH. Amidst all the “official” demands on day he decided simply to call two patients to see how they were doing. It proved to be a remarkable intervention as one was very near committing suicide. In debriefing other colleagues tried it to, with good success in relationship building and often some intervention or improvement in a patient’s care. ( A simple example of patient centered care)
The second dealt with the simple act of helping a disabled family structure a trust. His point was that to start building a response to the need, often, simple will work and that the energy today can be carried forward productive. He then listened for how action might be framed.
The meeting ended with leaders and participants highlighting themes of the day which included:
- It’s all “healthcare” since the mind and body are not truly separate
- We need to pick key practical initiatives and begin working on them with hope and perseverance.
- Communication, partnership and integration between Behavioral Health and Primary Care is essential
- Something must be done to improve the care of ED patients
- All of us must come together - public, private, delivery, financing, patients and families to make things happen.
Recorded by:
| Alden (Joe) Doolittle | Michael Trangle, MD |
| IBHI | HealthPartners |
| aldenjoe@ibhici.org | Michael.A.Trangle@healthpartners.org |
November 21, 2006
Appendix 1: Feedback and Participant Comments
Evaluation: Overall Review Range: 3.7 – 4.8, scale of 0-5. Mean 4.21
Comments regarding valuable features of this program included:
- Just having a program with this focus was great
- Wonderful opportunity to communicate with colleagues
- Being able to meet and talk with providers and administrators from other disciplines has been very helpful
- Presentation about St. Cloud Program was eye-opening
- Networking and establishing new contacts. New viewpoints on old issues
- The presentation of family and patient perspective was excellent
- HCMC ER presentation and Dr. Trangle’s Depression presentation were excellent
- Important learning what the system is trying to do to discharge people from the hospital, i.e. placement issues and standardizing
- Highly reputable speakers. Glad the day started with patient/family
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