Outcomes and payment models in crisis intervention

Here are a few notes and reflections about some of the things I'm thinking about today.

Treating Complex PTSD

I started out today reading about complex PTSD and DESNOS (Cloitre et al 2011). [quick rabbit trail: The layers of the crisis intervention field are deep. Makes me wonder about the history of the field and how it would be constructed.] The purpose of the article is to present a model for treatment of complex PTSD based in best practices. The authors explore how to treat the problem and in what order. Task 1: is "patient safety, symptom stabilization, and improvement in basic life competencies"; Task 2: "the exploration of traumatic memories for the purposes of first reducing acute emotional distress resulting from the memories and then reappraising their meaning and integrating them into a coherent and positive identity." Education about trauma, mindfulness & meditation, and symptom management CBT (cognitive behavioral treatment) seemed to rank pretty high as useful interventions.

Payment for Services

From there I jumped to a discussion at Shrink Rap about the pros & cons of capitated fee structures versus fee-for-service. The commentators quickly began promoting the Canadian healthcare system and calling each other names. Result: no decision.

Since this an interesting and timely topic (and I can write what I want in this space) let me opine also.

Capping payments (e.g., per member/per month model) is designed to allow providers flexibility in treating patients. A real plus of this system is that it allows budgeting to be based in reality. When you know your income resources can be allocated. The risk for providers is in managing the patient load by balancing the number of patients and the amount of care provided. Too few patients is risky for returning unearned funds, too many patients is risky for resentment and burnout. One other downside is the disconnect between each of the three poles: patient, funder, and provider.

Fee-for-service is designed to control costs using market factors. This system allows folks to buy whatever services they think they want/can afford. One risk is that patient's are often rely on their provider(s) (and marketing companies) for recommendations about health related purchases. A real plus is theoretical flexibility in provider and service selection. This system is favored by those who want to be rewarded directly for the number (and quality) of the services they provide.

Obviously, each model has benefits based on point of view.

Reflection

Prominently, outcomes and evidence-supported (based?) treatments are themes relative to both discussions. For a behavioral health care system to be most useful a requirement that patients can judge providers equally while providers can rely on treatment models.

So, I'm working in a crisis stabilization unit/detox at a standalone psychiatric hospital and I'm in a doctoral program in counselor education. I keep turning over what I'm doing and how I'm going to graduate. The answer is to write up what I'm interested in; what I'm interested in is usually whatever I'm doing. In this case I am interested in evaluating my presentation materials: what material is best to present to patients in withdrawal/early recovery with a 7-10 day average length of stay?

This isn't what brought me to school, but is a familiar idea. And a good one to keep in my back pocket. The patients are post-crisis intervention, so part of the evaluation could include the relationship of initial assessment/presenting problem to the admitting diagnosis and the discharge plan. How is the patient better prepared to return back to their environment after the intervention?

HRSA and licensure portability

The topic of licensure portability has particular importance in telehealth, where the entire premise is to deliver services across distances from pockets of providers to underserved regions. Urban centers often contain an abundance of providers, especially those connected to universities and teaching hospitals. Surrounding rural areas often do not have ready access to specialists (my interest is in behavioral health, and not just psychiatry but psychology, addictions, and talk therapies as well).

[may be that there is a map showing urban centers and the rural area they serve...probably yes, I just don't have one yet.]

While looking through some emails and chasing a few links today I ran across this discussion on the Telehealth Resource Center site on the Legal & Regulatory page:

Under Licensure and Scope of Practice, several models for cross state licensure agreements are presented. They include:

• Licensure by endorsement;
• Mutual recognition;
• Reciprocity;
• Special purpose or limited licenses.

The Health Resources and Service Administration (HRSA) reported to Congress about the issues. HRSA has an online resource center under their rural health section specifically related to telehealth. The page includes a broken link to the The Licensure Portability Grant Program (LPGP).

"The Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, is the primary Federal agency for improving access to health care services for people who are uninsured, isolated or medically vulnerable."

The emerging role of telehealth/telemedicine/mHealth in bridging the gaps to universal access to physiological and psychological healthcare continues to present opportunities for research and advocacy. One that I'll keep following with expectation for the next part of my career.

Instant Gratification: ED services and the future of healthcare

Sitting at my new desk, well actually an old kitchen table converted to a desk, in my new house, well actually its a rental, considering what to write that doesn't sound stupid or strays too far off topic. So much for not sounding stupid....

In my most recent life I was an emergency behavioral health assessor. In my new life I am a student who will be exposed to folks in a low-acuity hospital setting (its a hospital-based detox/crisis stabilization unit). This will help me flesh out understanding of the folks referred by assessors. This gap in my knowledge will be filled and will hopefully translate into better decision-making on the front end. Patients and their families will hate that; they want what the American medical system has taught them to want: instant gratification.

Which Way NC article about ED use and the Patient Protection and Affordable Care Act (ACA). I agree with Which Way NC's point that ED usage will increase as folks get less access to care and rationing leads to more crisis intervention services--by the way, clinicians hate this because they are trained to provide care to help people get better, not manage crises.

Check out this news: more funding cuts to the NC mental health system handed down from Raleigh. This link is from the Watauga Democrat in Boone, but it is happening across the state.

<blockquote>

"Across its service area, Smoky Mountain Center was dealt state cuts to several pots of funding, according to chief financial officer Lisa Slusher:

— $974,070 from its substance abuse block grant

— $1.67 million from its single-stream funding, which can be used for any age, disability or service

— $783,979 from its social services block grant, which provides for child mental health services and adult and child intellectual/developmental disabilities

— $48,000 for its drug treatment court in the northern region, which includes Watauga County

It also will operate with $113,574 less from county contributions."</blockquote>

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:

• 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