There are several winners after today's Supreme Court decision that the Affordable Care Act is constitutional. [Here is a link to the majority opinion.] Among them are insurance carriers, rural hospitals, folks who can't afford insurance, and consumers of behavioral health services. Losers include those who can afford to self-insure and those with no intention of paying for services received. Other writers can spin this differently, but part of what I sense from those who oppose the law is a selfishness and very narrow in-group definition.
There are problems in this country related to basic fairness. Problems from those who think that everyone is trying to get something for nothing and those who are indeed seeking a free lunch.
My biggest concern about this law continues to be how it will be funded and implemented. Adding "accountability" will encourage reviewers to find problems with documentation--this will be called fraud, but could be as simple as not signing a note quickly enough. It will also stifle therapeutic innovation and professional development in favor of "manualized treatment" and credentialing of lower level staff by state agencies.
Private insurance carriers and major hospital systems have begun to institute reforms touted in the law. This is because there are ways to streamline care while increasing quality and access. In many ways, the marketplace will solve problems when the environment changes and lead the way to a higher level of care. When politicians enter the business landscape things get complicated and lead to a lower level of care. I keep remembering a time I wanted to pay the IRS using a debit card; that experience showed me the worst of regulation and business--regulations designed to protect me combined with the convenience fee of the immediate service.
I expect the frontiers of healthcare reform to be in the expansion of "evidence-based treatments" by academic researchers--often supplementing eroding salaries with grant-funded projects and sales of programs--and crisis services. Reducing access to behavioral health services will continue to promote the use of crisis services.
Anyway, I hail the law and the increased access to healthcare it brings. My elation is tempered by experience in a rationed system. But...we'll see. The whole thing has to play out.
Thursday, June 28, 2012
What is a "crisis hotline"?
An effective crisis response system is built from many pieces, each piece designed to provide an interrupt, or stop, where folks can breathe and disrupt the escalation of their crisis. The initial interrupt occurs at the point the person reaches out for formal assistance. (Technically, the first interrupt is when the person realizes they are overwhelmed, in crisis, and uses their personal resources and friends, sometimes called "natural supports", to resolve the crisis. While these informal efforts may not be recognized as deescalation attempts they are very important to management of the crisis.) One point of entry into the system is through the telephone crisis hotline.
“Crisis hotline” is the generic name given to services designed to provide immediate, usually, telephonic response for persons experiencing an acute crisis event. The hotline may serve various purposes, including Information and Referral (I&R) warmlines, telephonic crisis counseling, and dispatching mobile interventions and rescue efforts.
In some regions specialized services exist for specific populations and problems; in other regions calls may be answered by generalists who have experience in a wider variety of problems. One area I am familiar with has the 911 emergency response for medical/fire/law enforcement response, a dedicated domestic abuse response line, and a behavioral health line. They work together to route callers to the most appropriate responder.
In some regions specialized services exist for specific populations and problems; in other regions calls may be answered by generalists who have experience in a wider variety of problems. One area I am familiar with has the 911 emergency response for medical/fire/law enforcement response, a dedicated domestic abuse response line, and a behavioral health line. They work together to route callers to the most appropriate responder.
Hotlines are staffed with trained persons who may be licensed mental health professionals, unlicensed mental health specialists, or peer supporters. In some states, Ohio, for instance, the term "counseling" may only be used by a licensed counselor. So, while the caller may not receive “counseling” services on the phone, they will be talking with a trained phone responder who may provide a suicide risk assessment, crisis intervention, and referral to community services as needed.
Albert Roberts, PhD created the 7-stage crisis intervention model in use by many crisis lines. The model's seven stages are:
1. plan and conduct a thorough biopsychosocial and lethality/imminent danger assessment;
2. make psychological contact and rapidly establish the collaborative relationship;
3. identify the major problems, including crisis precipitants;
4. encourage an exploration of feelings and emotions;
5. generate and explore alternatives and new coping strategies;
6. restore functioning through implementation of an action plan;
7. plan follow-up and booster sessions.
2. make psychological contact and rapidly establish the collaborative relationship;
3. identify the major problems, including crisis precipitants;
4. encourage an exploration of feelings and emotions;
5. generate and explore alternatives and new coping strategies;
6. restore functioning through implementation of an action plan;
7. plan follow-up and booster sessions.
Early crisis lines were organized in the 1950’s to provide suicide prevention services and have grown into networks of crisis centers able to respond to specific populations and circumstances nationwide. Suicide is now seen as a public health problem by policymakers and resources are available to strengthen a national network of suicide prevention call centers. "Many people trace official interest in the subject to a Senate resolution, introduced in 1997 by Senator Harry Reid, Democrat of Nevada, whose father killed himself, which proclaimed reducing suicide a national priority."
Mobile technologies offer challenges to rescuers and opportunities for folks to get help. As technology changes it is essential that crisis systems evolve. Call centers are learning to use social media, SMS/"texting", internet chat, and other technology to give folks options for confidential help with crisis intervention and de-escalation. Stop Teenage Suicide is an example. SAMHSA and Facebook teamed up in Dec 2011:
Mobile technologies offer challenges to rescuers and opportunities for folks to get help. As technology changes it is essential that crisis systems evolve. Call centers are learning to use social media, SMS/"texting", internet chat, and other technology to give folks options for confidential help with crisis intervention and de-escalation. Stop Teenage Suicide is an example. SAMHSA and Facebook teamed up in Dec 2011:
"The new service enables Facebook users to report a suicidal comment they see posted by a friend to Facebook using either the Report Suicidal Content link or the report links found throughout the site. The person who posted the suicidal comment will then immediately receive an e-mail from Facebook encouraging them to call the National Suicide Prevention Lifeline 1-800-273-TALK (8255) or to click on a link to begin a confidential chat session with a crisis worker."
Besides adding points of access for those in crisis, chat and texting extend the availability of staff resources. While Information and Referral (I&R) warmlines and runaway assistance centers can often operate on a limited-time schedule, acute crisis response hotlines must be available with 24-hour telephone service 7 days a week to provide counseling, guidance, emotional support, information and referral, and rescue interventions.
Mobile phones challenge emergency responders to locate suicidal callers due to the very advantage of cellphones: mobility. When you can't locate a caller, response time may be extended. Increasing the sensitivity of GPS tracking with smartphones offers promise but raises privacy concerns.
Examples
- 1-800-SUICIDE 1-800-784-243
- 1-800-273-TALK 1-800-273-8255
- 1-800-799-4TTY (4889) Deaf Hotline
- 1-866-COP-2COP
An Online Crisis Network
The first online network with 100% of its volunteers trained and certified in crisis intervention.
Thursday, June 14, 2012
Moody's promotes Obamacare
Today it was reported that Moody's Investors Service supports "Obamacare", the Patient Protection and Affordable Care
Act, because it provides a greater income base for non-profit hospitals. They are not as happy about reductions in Medicare payments for physicians, also included in the law.
I have been casually following the progress of this law and public challenges it faces with several thoughts in mind.
Good question. One worth spending some time with. If crisis services continues to be where the money is spent, clearly training and technology must adapt.
I have been casually following the progress of this law and public challenges it faces with several thoughts in mind.
- It is a good thing for all persons to have insurance. The more people have insurance the more costs can be spread and, at least theoretically, that should lower retail healthcare. I say that knowing that prices always go up, never down. I am reminded of the premiums paid for organic foods.
- In North Carolina, mental healthcare reform led to increased rationing and increased overhead due to increased "accountability" to enforce fraud laws and to use recoupments to balance the budget. This created a very dicey environment for providers and additional layers of administration that were funded with lower reimbursements for services.
- Reduced services (not access, it is a policy goal to increase access) has led to increased importance of the crisis and intake assessments in promoting good behavioral health and "recovery engagement". This is not the system I was trained for in graduate school; true for most providers, surely.
- While the politicians wrangle over power and donations business (especially insurance carriers and hospitals) is adapting to the new model(s).
Good question. One worth spending some time with. If crisis services continues to be where the money is spent, clearly training and technology must adapt.
Monday, June 11, 2012
Ranting About Documentation
Over the course of the past week or so I've been confronted by the question of what is enough when collecting information for a crisis assessment. These are the assessments conducted on the patient who presents in a behavioral health "crisis". The purpose of the assessment is to determine the most appropriate level of care and safety plan so the patient can be directed at the end of the session.
In general, this is a routine intervention. Get a little history to flesh out the presenting problem and make some recommendations for follow-up care.
It is a problem when the documentation does not support the diagnosis or justify the recommended level of care. At least that's the way my thinking has evolved.
Guiding Principle 1: Albert Roberts, PhD 7-stage crisis intervention model.
Guiding Principle 2: The patient's medical record describes the patient.
Guiding Principle 3: Recovery works best when the patient can see individual crisis events and treatment episodes as part of a continuum.
It offends my professional ego when these principles are violated/ignored/not attended to. Period. Breathe...1...2...3...4...5...better now....
But then I ask if I'm just being pretentious or overbearing or taking some other negative stance.
Probably.
And, I wonder, because I can't not argue with myself, what is the minimum of good documentation? Certainly there must be enough story to justify a diagnosis and medical necessity for the recommended level of care. I guess that can be done in 5 sentences or less.
But I doubt it. "When in doubt, get more history" one of my professors used to say. Should I say, "doubt is good?"
Yes, if it can be documented....
In general, this is a routine intervention. Get a little history to flesh out the presenting problem and make some recommendations for follow-up care.
It is a problem when the documentation does not support the diagnosis or justify the recommended level of care. At least that's the way my thinking has evolved.
Guiding Principle 1: Albert Roberts, PhD 7-stage crisis intervention model.
Guiding Principle 2: The patient's medical record describes the patient.
Guiding Principle 3: Recovery works best when the patient can see individual crisis events and treatment episodes as part of a continuum.
It offends my professional ego when these principles are violated/ignored/not attended to. Period. Breathe...1...2...3...4...5...better now....
But then I ask if I'm just being pretentious or overbearing or taking some other negative stance.
Probably.
And, I wonder, because I can't not argue with myself, what is the minimum of good documentation? Certainly there must be enough story to justify a diagnosis and medical necessity for the recommended level of care. I guess that can be done in 5 sentences or less.
But I doubt it. "When in doubt, get more history" one of my professors used to say. Should I say, "doubt is good?"
Yes, if it can be documented....
Saturday, June 9, 2012
Problem Behaviors in the ED: “Hostage taking”
Sometimes patients are brought to the emergency department by law enforcement, or another authority, for a behavioral health evaluation and development of a safety plan. Behavioral health evaluations have the initial goal of determining risk for imminently dangerous behavior. Evaluations consist of two significant portions: a medical screening and a psychosocial history gathering. These evaluations contribute data to the risk assessment and are used to create the safety plan. Safety plans can take many forms depending upon the risks, resources, and circumstances of individual cases.
Most of these involuntary evaluations are managed without incident; but, sometimes the patient refuses to participate in the process. When a patient fails to cooperate with either assessment component they may be considered to be holding the process hostage.
Over the past few weeks several examples of hostage taking behavior have presented themselves in “my” ED. One fellow came in after a police standoff and refused to talk to anyone or give a urine sample to complete the medical screen, another was intoxicated and LOUD and kept several police officers busy until he went to sleep, a restless lady presenting a flight risk, and one older retired professor with behavior problems secondary to dementia. Each case presented different dimensions of the same idea: hostage-taking behaviors.
In the basic hostage situation one person takes control of another person and refuses to release them. The goal is to trade the captive for some good. When the behavioral health patient holds an ED hostage they are controlling the assessment process. It is not always clear what the patient’s goal is, but can usually be framed around the desire to dictate terms of release. There is often a narcissistic reach for power in action.
The patient that takes the assessment process hostage is holding a desperate position in a lose-lose game. Such a position is played from a place of powerlessness, where the patient is seeking control of their situation and/or emotions. Although they may not realize it, this patient is the most powerful person in the room.
One of the behavioral health worker’s tasks is to promote the patient’s feelings of power and channel that power into the development of the safety plan and, ultimately, into their taking control of their recovery.
What tools are available to respond to the hostage-taker?
Well, I fully believe in paying attention to the basics of patient care and behavior management. The stronger the foundation, the better plans can be built. Responding to hostage-taking behaviors is no exception. That means promote respect and dignity, practice effective communication, and observe positive behavior management strategies.
As a refresher, here is a reminder of what behavior is/isn’t (from [1])
BEHAVIOR IS:
BEHAVIOR IS NOT:
And the ABCs of behavior management:
A=Antecedent: The event occurring before a behavior.This event prompts that behavior.
B=Behavior: Response to the events that can be seen or heard.
C=Consequence: The event(s) that follow(s) the behavior.This effects whether the behavior will occur again.
Regarding the importance of communication (from [2])
“Effective communication is an essential part of caring for patients. Yet there is evidence that in practice communication continues to be problematic.
The research base shows that: Poor communication can have serious consequences leading to complaints by patients and their relatives
Poor communication can leave patients feeling dissatisfied, frustrated, anxious and so uncertain that it affects their ability to comply with recommended treatments
Good communication can influence patients’ emotional health, symptom resolution, function and physiological measures such as blood pressure as well as decrease reported pain and drug usage
Insufficient training in communication is a major factor contributing to stress, lack of job satisfaction and emotional burnout in healthcare professionals”
To set up an effective box to provide for safety of the patient and community in the ED setting a few things are necessary.
Remove the patient to the least stimulating area available, where they can be observed without being the focus for other visitors. This reduces attention and stimulation, promotes dignity, and creates a situation where the patient can deescalate safely.
Make the patient as comfortable as possible within the confines of the treatment environment. Emergency departments are not designed for comfort, they are designed for efficiency. But the offer of a pillow, warm blanket, decaf drink, and food can go a long way in developing rapport—and, ultimately, the safety plan.
The tincture of time will do the rest. There is no need to do much more. Nursing care is generally not required once the patient has been installed in a calm setting. If the patient is in custody they are confined to a small area and not a threat for wandering. Nature will do more to dictate when samples are obtained for the medical screen than anything that you can do.
The biggest mistake made in the ED setting, in my opinion, is to respond to challenging patient behaviors with a power struggle. Power struggles are demeaning to staff and patient. More importantly, they escalate the very behaviors that provide the challenge.
The flow of the emergency behavioral health assessment and safety planning process flow begins with recognition of the position of the patient. Powerlessness is the presenting cognitive position more often than not. In the search for power patients may resort to hostage taking behaviors. Effective management of these behaviors is built with empathy and respect by the ED staff for the patient and allowing time to work its magic in deescalating the patient’s emotional state.
RELAX, it’ll be all right….
Cites:
[1] Retrieved by rmcox on 2 june 2012 from http://www.bbbautism.com/behavior_management_strategies.htm
[2] Retrieved 01 june 2012 by rmcox from http://www.connected.nhs.uk/index.php?option=com_content&view=article&id=2&Itemid=2
Most of these involuntary evaluations are managed without incident; but, sometimes the patient refuses to participate in the process. When a patient fails to cooperate with either assessment component they may be considered to be holding the process hostage.
Over the past few weeks several examples of hostage taking behavior have presented themselves in “my” ED. One fellow came in after a police standoff and refused to talk to anyone or give a urine sample to complete the medical screen, another was intoxicated and LOUD and kept several police officers busy until he went to sleep, a restless lady presenting a flight risk, and one older retired professor with behavior problems secondary to dementia. Each case presented different dimensions of the same idea: hostage-taking behaviors.
In the basic hostage situation one person takes control of another person and refuses to release them. The goal is to trade the captive for some good. When the behavioral health patient holds an ED hostage they are controlling the assessment process. It is not always clear what the patient’s goal is, but can usually be framed around the desire to dictate terms of release. There is often a narcissistic reach for power in action.
The patient that takes the assessment process hostage is holding a desperate position in a lose-lose game. Such a position is played from a place of powerlessness, where the patient is seeking control of their situation and/or emotions. Although they may not realize it, this patient is the most powerful person in the room.
One of the behavioral health worker’s tasks is to promote the patient’s feelings of power and channel that power into the development of the safety plan and, ultimately, into their taking control of their recovery.
What tools are available to respond to the hostage-taker?
Well, I fully believe in paying attention to the basics of patient care and behavior management. The stronger the foundation, the better plans can be built. Responding to hostage-taking behaviors is no exception. That means promote respect and dignity, practice effective communication, and observe positive behavior management strategies.
As a refresher, here is a reminder of what behavior is/isn’t (from [1])
BEHAVIOR IS:
- Any action that can be seen or heard
- Is observable
- Is measurable
BEHAVIOR IS NOT:
- Your reaction to the situation
- Your interpretation of the situation
- Your expansion of the situation
And the ABCs of behavior management:
A=Antecedent: The event occurring before a behavior.This event prompts that behavior.
B=Behavior: Response to the events that can be seen or heard.
C=Consequence: The event(s) that follow(s) the behavior.This effects whether the behavior will occur again.
- When the behavior is followed by a pleasant consequence, it is more likely to reoccur.
- When the behavior is followed by an unpleasant consequence, it is less likely to reoccur.
Regarding the importance of communication (from [2])
“Effective communication is an essential part of caring for patients. Yet there is evidence that in practice communication continues to be problematic.
The research base shows that: Poor communication can have serious consequences leading to complaints by patients and their relatives
Poor communication can leave patients feeling dissatisfied, frustrated, anxious and so uncertain that it affects their ability to comply with recommended treatments
Good communication can influence patients’ emotional health, symptom resolution, function and physiological measures such as blood pressure as well as decrease reported pain and drug usage
Insufficient training in communication is a major factor contributing to stress, lack of job satisfaction and emotional burnout in healthcare professionals”
To set up an effective box to provide for safety of the patient and community in the ED setting a few things are necessary.
Remove the patient to the least stimulating area available, where they can be observed without being the focus for other visitors. This reduces attention and stimulation, promotes dignity, and creates a situation where the patient can deescalate safely.
Make the patient as comfortable as possible within the confines of the treatment environment. Emergency departments are not designed for comfort, they are designed for efficiency. But the offer of a pillow, warm blanket, decaf drink, and food can go a long way in developing rapport—and, ultimately, the safety plan.
The tincture of time will do the rest. There is no need to do much more. Nursing care is generally not required once the patient has been installed in a calm setting. If the patient is in custody they are confined to a small area and not a threat for wandering. Nature will do more to dictate when samples are obtained for the medical screen than anything that you can do.
The biggest mistake made in the ED setting, in my opinion, is to respond to challenging patient behaviors with a power struggle. Power struggles are demeaning to staff and patient. More importantly, they escalate the very behaviors that provide the challenge.
The flow of the emergency behavioral health assessment and safety planning process flow begins with recognition of the position of the patient. Powerlessness is the presenting cognitive position more often than not. In the search for power patients may resort to hostage taking behaviors. Effective management of these behaviors is built with empathy and respect by the ED staff for the patient and allowing time to work its magic in deescalating the patient’s emotional state.
RELAX, it’ll be all right….
Cites:
[1] Retrieved by rmcox on 2 june 2012 from http://www.bbbautism.com/behavior_management_strategies.htm
[2] Retrieved 01 june 2012 by rmcox from http://www.connected.nhs.uk/index.php?option=com_content&view=article&id=2&Itemid=2
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