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Improving Healthcare Quality: Advanced Clinic Access in Mental Health
Mary Schohn, Ph.D.
April 24, 2004
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
Roadmap to improvement
Identify gaps between current performance and desired performance
Seek new designs Involve everyone (Berwick, 2003)
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
Improvement in Average Next Available Appointment
Reduction in Wait Times While Patients Increase
Mental Health and ACA
Director’s Performance Measure FY04 Added three Mental Health Clinics (502, 509, 510) to the ACA
Initiative for reducing waiting times Director’s 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
Current status
Stopcode
Next Available Wait
# of New Appointments
Total New Appoint Wait
Percent of Next Avialable Seen in 30 days
502 22.4 39,436 30.7 78.38%509 24.1 11,966 34.4 76.26%510 18.3 8,267 21.5 86.78%513 8.4 7,778 12 94.29%516 3.5 493 37.6 97.39%525 34.8 75 13.4 34.55%530 239.7 6 0 0.00%531 20.3 5,437 29.6 80.56%538 25.2 2,139 42.4 82.08%540 18.4 4,434 30.2 82.64%547 2.9 2,846 8.3 99.12%561 5.8 2,270 37.5 98.28%562 23.9 844 46.2 80.23%576 26.3 1,088 47.8 73.93%
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
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.
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
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
Common Strategies used in Mental Health ACA in VA Shape the Demand
Reduce the Demand Reduce return rate visits “what’s 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
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
Common Strategies Used in Mental Health ACA in VA Redesign System to Increase Supply
Optimize the care team Review team functions and assignments – don’t
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
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
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
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
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
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
Resources
VISN MH POC MH ACA Mail group MH ACA Satellite Videoconference
August, 2004