CAMH DropIn Bridging Service Dr Brittany Poynter Shayla

CAMH Drop-In Bridging Service Dr. Brittany Poynter, Shayla Gutzin, Natalie Quick, and Susan Anderson CAMH – Centre for Addiction and Mental Health Aim Statement System Aim: By March 31 2018, we will reduce CAMH ED visits by 10%. Project Aim: By March 31, 2018 50% of patients attending the Bridging Service after an inpatient stay will have their first appointment within 7 days of their discharge date. This will, in turn, reduce the overall ED visit volumes at CAMH System Aim Outcome Measures: • Number Assessed in ED* per week • Percent Assessed in ED* per week • Number Assessed in ED *11 -4 • Percent Assessed in ED *11 -4 • * When appropriate, CAMH Emergency Dept. triaged some to Bridging, not ED assessment Process Measures: • Average Wait on Arrival • Attending Inpatients Avg. Time to Attend • Visits • Breakdown of Referring Unit for Visits • New Clients • Patient Satisfaction Scores • WHODAS – WHO Disability Assmt. Schedule Balancing Measure: • 30 Day Inpatient Readmission Results During IDEAS Diagnostics A driver diagram identified change ideas: We met our system aim: • pre-IDEAS: ED assessed 223. 4 per week. • post- IDEAS: 11. 1% less at 198. 6. per week • of people who register 11 am-4 pm, the ED went from assessing avg. of 94. 6% to 84. 1% Project aim data was inconclusive: • poor data quality on inpatients’ time to attend High patient satisfaction in voluntary survey • average scores above 3/4 on all questions. Positive impacts for many stakeholders: • clients had accessible care post-discharge • ED staff could focus on emergencies • outpatient support is more cost-effective than emergency and inpatient care Bridging has expanded due to its success. Since July 9, 2018, the service now: • operates 9 -5 Monday to Friday • triages all patients referred to urgent care • has increased physician resources • has merged with Crisis Clinic to further increase staffing and simplify patient flow 1. 100 1. 000 0. 900 UCL 1. 0000 CL 0. 946 LCL 0. 851 0. 800 Bridging Opens 0. 700 Mar 5 - Mar 11 Feb 26 - Mar 4 Feb 19 - Feb 25 Feb 12 - Feb 18 Jan 29 - Feb 2 Feb 5 - Feb 11 Jan 22 - Jan 28 Jan 15 - Jan 21 Jan 8 - Jan 14 Jan 1 - Jan 7 Dec 25 - Dec 31 Dec 18 - Dec 24 Dec 11 - Dec 17 Dec 4 - Dec 10 Nov 27 - Dec 3 Nov 20 - Nov 26 Nov 13 - Nov 19 Oct 30 - Nov 5 Nov 6 - Nov 12 Oct 23 - Oct 29 Oct 16 - Oct 22 Oct 9 - Oct 15 Oct 2 - Oct 8 Sept 25 - Oct 1 Sept 18 - Sept 24 Sept 11 - Sept 17 Sept 4 - Sept 10 Aug 28 - Sept 3 Aug 21 - Aug 27 Aug 14 - Aug 20 Aug 7 - Aug 13 July 31 - Aug 6 0. 500 July 24 - July 30 0. 600 July 17 - July 23 Measures Spread p Chart - of Patients Registered in ED 11 am-4 pm Weekdays, Proportion of Patients with Completed Assessments per Week July 10 - July 16 • Key change: Bridging opened 1 -5 pm Monday to Friday starting Oct. 23, 2017 • PDSAs – gradually tested if daily/weekly inpatient unit visits engaged clients • Informal Changes: • Daily problem solving in huddles • Refining triage flow with team Chart July 3 - July 9 In the past, 8% of Centre for Addiction and Mental Health (CAMH) inpatients received physician follow-up within a week of discharge. From selected units, 19. 2% of patients returned to the CAMH Emergency Department (ED) less than 30 days postdischarge and 13. 5% were readmitted. There was a clear need for accessible postdischarge mental health and addictions services, which was likely contributing to growing CAMH ED volumes. The Bridging Service was opened to address this after two successful pilot programs. It provides drop-in mental health and addictions support for targeted patients referred from CAMH ED or inpatient units. Intervention/Change Ideas Proportion Assessed in ED of those Registered Weekdays 11 am-4 pm Problem Statement Week This shows that when Bridging opened, the proportion of people assessed in the ED reduced during the hours that patients appropriate for Bridging were diverted there. The new model is being closely monitored. The Bridging team is also sharing our stories and results with interested groups within and beyond CAMH, some of whom are applying what we have learned to their own projects. A chart not shown confirms the proportion assessed 11 -4 lowered from 0. 946 to a new stable baseline of 0. 841. Organizational Enablers Bridging Service benefitted from strong organizational support: • it aligned with all of CAMH’s strategic directions e. g. : • improving access • earning a reputation for service and accountability • interprofessional leadership strongly encouraged building QI capacity • leadership support helped us successfully engage all staff early on Sustainability Staff and patient ideas and the NHS Sustainability Guide led us to: • brainstorm with staff about change ideas to improve flow and data quality • do a PDSA that confirmed a using screener focused assessments • upgrade furniture and entryway • simplify our PDSA process • prioritize which measures to chart Next Steps/ Lessons Learned Overall, this project showed that leadership support, funding, and stakeholder engagement are keys to success. As the drop-in model was new, we learned: • visits’ volume & nature were unpredictable • we needed to monitor if staff met demand • we had to build and adjust a new workflow • measures had to meet range of needs (QI, leadership/ministry needs, feasibility) PDSAs worked best when simple and brief. Now, helping those taking over from our IDEAS team is key to sustaining this work. We continue improving the expanded model. Contact Name: Title: Org. : Email: Phone: Dr. Brittany Poynter Medical Head – Emergency Department, Access CAMH, & General Psychiatry Ambulatory Services CAMH Brittany. Poynter@camh. ca 416 -535 -8501 ext. 30403