Medical and Behavioral Health: A Delicate Balance

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Medical and Behavioral Health: A Delicate Balance Mae Centeno DNP, RN,

Director BUMC Nursing Service Support 1 Background Co-Morbid Behavioral Condition

discontinuation or delay of treatment Impacts length of stay Elderly at risk for

seniors or in nursing homes have depression 3 Two-fold increases risk of older adults

Highly prevalent, behavioral disorders have a significant economic and social impact

The impact of psychiatric comorbidity on general 2 hospital length of stay

1 Medical and Behavioral Health: A Delicate Balance Mae Centeno DNP, RN, CCRN,CCNS,ACNS-BC Corporate Director Chronic Care Continuum Jeff Place MSN,MBA,RN Director BUMC Nursing Service Support 1 Background Co-Morbid Behavioral Condition Impact: Quality and Finance Unrecognized in an acutely hospitalized patient 1 Causes discontinuation or delay of treatment Impacts length of stay Elderly at risk for slightly longer length of stay 2 May increase readmission 25 to 40 % of hospitalized seniors or in nursing homes have depression 3 Two-fold increases risk of older adults with depression developing Alzheimer's disease 1 American Hospital Association. Highly prevalent, behavioral disorders have a significant economic and social impact Jan Bressi, SK, Marcus, SC. The impact of psychiatric comorbidity on general 2 hospital length of stay Psychiatric Q (2006)77: CDC Co-Morbid Behavioral Condition: Raises Cost The presence of mental health disorder raises treatment costs for chronic medical conditions. 3 1

Environment Finance Multiple Providers Lack of knowledge Lack of inpatient behavioral resources Increase LOS Cost of medications Incomplete Med Rec No standardized tool to

Equipment Process 4 Discontinuation or delay in initiating behavioral meds prolong length of stay Can cause discontinuation syndrome Discontinuation Syndrome 5 Discontinuation

24-48 hours after drug discontinuation or dose reduction Symptoms last up to 7-14 days Cause morbidity and can be misdiagnosed 72% of psychiatrists and 30% of general practitioners

2 Environment Finance Multiple Providers Lack of knowledge Lack of inpatient behavioral resources Increase LOS Cost of medications Incomplete Med Rec No standardized tool to Behavioral history Assess behavioral health not always disclosed Behavioral history/meds not always documented Meds not continued on admission or not resumed after procedures Equipment Process 4 Discontinuation or delay in initiating behavioral meds prolong length of stay Can cause discontinuation syndrome Discontinuation Syndrome 5 Discontinuation Syndrome (DS) A condition in which the patient experiences adverse effects that result from abrupt discontinuation of medication rebound effect Symptoms begin within the first hours after drug discontinuation or dose reduction Symptoms last up to 7-14 days Cause morbidity and can be misdiagnosed 72% of psychiatrists and 30% of general practitioners have knowledge and understanding of DS 6 Lamoure J, Stovel J. Abrupt Stop: Managing Discontinuation Syndrome Associated with Psychoactive Medications. Pharmacy Practice. 2010; 26 (5) Sept 2010: 40-47,53 2

Characteristics of Discontinuation Syndrome Disequilibrium Dizziness, vertigo or ataxia Lethargy, headache, tremor, sweating

Gastrointestinal Anorexia, nausea, vomiting Sensory disturbances Paresthesia (tingling or pricking of your skin) Numbness,

Delirium Following Abrupt Discontinuation of Fluoxetine. Clinical Neurology and Neurosurgery 110(2008) 69-70 Lamoure J, Stovel J.

2010; 26 (5) Sept 2010: 40-47,53 7 Robinson, D.S. (2006). Antidepressant Discontinuation Syndrome.

Medications Associated with DS Medication Class Tricyclic Anti depressants Selective serotonin reuptake inhibitors (SSRI)

psychotics Benzodiazepines 30% of the population will require an agent in one of these classes in their lifetime Lamoure J, Stovel

3 Characteristics of Discontinuation Syndrome Disequilibrium Dizziness, vertigo or ataxia Lethargy, headache, tremor, sweating Irritability, anxiety, agitation or low mood, mania Sleep disturbances Insomnia, nightmares, or excessive dreaming Gastrointestinal Anorexia, nausea, vomiting Sensory disturbances Paresthesia (tingling or pricking of your skin) Numbness, electric-shock-like sensations Flu-like symptoms Blum, D., Maldonado, J. et al. Delirium Following Abrupt Discontinuation of Fluoxetine. Clinical Neurology and Neurosurgery 110(2008) Lamoure J, Stovel J. Abrupt Stop: Managing Discontinuation Syndrome Associated with Psychoactive Medications. Pharmacy Practice. 2010; 26 (5) Sept 2010: 40-47,53 7 Robinson, D.S. (2006). Antidepressant Discontinuation Syndrome. Primary Psychiatry, 13(10):23-24 HELP! Medications Associated with DS Medication Class Tricyclic Anti depressants Selective serotonin reuptake inhibitors (SSRI) Serotonin norepinephrine reuptake inhibitor (SNRI) Norepinephrine acetylcholine serotonin selective agents (NaSSas) Atypical anti psychotics Benzodiazepines 30% of the population will require an agent in one of these classes in their lifetime Lamoure J, Stovel J. Abrupt Stop: Managing Discontinuation Syndrome 8 Associated with Psychoactive Medications. Pharmacy Practice. 2010; 26 (5) Sept 2010: 40 47,53 Aim Statement To increase the number of behavioral health medications continued on admission by 15% in patients admitted to 3Truett with co-morbid behavioral condition by June 30, 2013 through staff education. 9 3

Timeline and Evaluation Baseline period August to September 2012 Team Formation and Meetings Communication Staff Survey Staff

2013 Project Evaluation June to July 2013 Evaluation: Increase in the number of patients with behavioral medications continued

evaluation 10 RN Survey Questions: 25 Respondents 1.

I have the skill to identify behavioral changes/crisis in patients under my care 3.

It is my responsibility as a nurse to follow up with a physician to resume medications held/discontinued for diagnostic reasons

4 Timeline and Evaluation Baseline period August to September 2012 Team Formation and Meetings Communication Staff Survey Staff Education Team regroup Team re-group December 2012 October 2012 November 2012 to January 2013 Implementation February to May 2013 Project Evaluation June to July 2013 Evaluation: Increase in the number of patients with behavioral medications continued during hospitalization Decrease length of stay caused by delay in resuming behavioral health medications after diagnostic evaluation 10 RN Survey Questions: 25 Respondents 1. Discontinuation of psych meds or delay in treating behavioral issues impact length of stay 2. I have the skill to identify behavioral changes/crisis in patients under my care 3. Med Rec on admission is vital to optimal patient outcomes 4.It is my responsibility as a nurse to follow up with a physician to resume medications held/discontinued for diagnostic reasons once the diagnostic evaluation is completed 5. Treating behavioral problems is equally important to addressing medical problems 6. It is my responsibility to know the side effects of the medications I administer to my patients Strongly Agree Agree Disagree Strongly Disagree Survey conducted November Process Flow 12 4

5 Rate of Patients with Behavioral Health Conditions 100% 90% 57.5% Monthly average of patients with co-morbid behavioral health 80% 70% 60% 50% 40% 30% 20% 10% 0% 13 August 1 31, 2012 September 1 30, 2012 February 1 28, 2013 March 1 31, 2013 April 1 30, 2013 May 1 31, 2013 Behavioral Health Conditions Baseline Period August 1 to September 30, 2012 N=32 Measurement Period February 1 to May 31, 2013 N=59 Depression 11 (34.3%) 27 (45.7%) Bipolar Disorder 7 (21.8%) 7 (11.8%) ETOH/Poly-substance 5 (15.6%) 4 (6.7%) Anxiety 3 (9.3%) 9 (15.2%) Schizophrenia 3 (9.3%) 2 (3.3%) Suicidal 2 (6.2%) 1 (1.6%) Mood Disorder 1 (3.1%) 9 (15.2%) 14 Outcomes: Medications Continued or Started on Admission 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Medications Continued/Started on Admission Direction of improving performance 15 5

6 Outcomes: Behavioral Medications Started 2 Days Later % Medications Started Within 2 Days Later % 80.00% 60.00% 40.00% 20.00% 0.00% 16 Direction of improving performance Outcomes: Behavioral Medications Started > 3 Days Later 45% Medications Started >3 Days 40% 35% 30% 25% 20% 15% 10% 5% 0% 5% August 1 August 16 September September Feb 1 15, Feb 15 28, March 1 15, March 16, April 1 15, April 16 30, May 1 15, May 16 15, , , , , , 2013 Direction of improving performance Outcomes: Behavioral Medications Not Started/Held 70.00% 60.00% 50.00% Medications Not Started/Held Due to medical condition 40.00% 30.00% 20.00% 10.00% 0.00% Direction of improving performance 18 6

Outcomes Behavioral Health Medications Aug 1to Sept 30, 2012 N = 32 Baseline Feb 1 to May 31, 2013 N=59

6%) 16 (27.11%) Meds started 2 days later 5 (15.6%) 1 (1.6%) Meds started >3 days 7 (21.8%) 2 (3.

55%)* *Psych Consults were ordered on patients 19 whose behavioral meds were started 2 >days (3), held or not

Baseline Period N=10 patients (31.2%) Measurement Period N = 5 patients (8.

Discontinuation of psych meds or delay in treating behavioral issues impact length of stay 2.

Med Rec on admission is vital to optimal patient outcomes 4.

diagnostic reasons once the diagnostic evaluation is completed 5.

7 Outcomes Behavioral Health Medications Aug 1to Sept 30, 2012 N = 32 Baseline Feb 1 to May 31, 2013 N=59 Measurement Meds continued or 11 (34%) 35 (59.32%) started on admission Meds started 1 day later 5 (15.6%) 16 (27.11%) Meds started 2 days later 5 (15.6%) 1 (1.6%) Meds started >3 days 7 (21.8%) 2 (3.3%) Meds not started/held 4 (12.5%) 5 (8.47%) Psych Consult 19/32 (59%) 8/59 (13.55%)* *Psych Consults were ordered on patients 19 whose behavioral meds were started 2 >days (3), held or not started (5) Outcomes: Delayed Discharge Number of days discharged delayed related to behavioral condition Baseline Period N=10 patients (31.2%) Measurement Period N = 5 patients (8.4%) 6 days 2 Days 20 RN Survey: Pre and Post Questions: 1. Discontinuation of psych meds or delay in treating behavioral issues impact length of stay 2. I have the skill to identify behavioral changes/crisis in patients under my care 3. Med Rec on admission is vital to optimal patient outcomes 4.It is my responsibility as a nurse to follow up with a physician to resume medications held/discontinued for diagnostic reasons once the diagnostic evaluation is completed 5. Treating behavioral problems is equally important to addressing medical problems 6. It is my responsibility to know the side effects of the medications I administer to my patients Strongly Agree Agree Disagree Strongly Disagree Pre Post Pre Post Pre Post Pre Post Pre= 25 respondents 21 Post = 21 respondents 7

Summary of Outcomes Increase behavioral medications continued on admission by 25.

5% Patients needing psych consult Patients with delayed discharge Days discharge is delayed by 4 days Need for further nursing education

6 days 5 Patients with delayed discharge of 2 days o 3 Medicare o 1 Medicaid o 2 Managed Care o 1 Managed Medicaid o 3 Self pay o 1

8 Summary of Outcomes Increase behavioral medications continued on admission by % Decrease in the number of : Behavioral medications started > 3 days by 18.5% Patients needing psych consult Patients with delayed discharge Days discharge is delayed by 4 days Need for further nursing education 22 Financial Analysis: Profit and Loss 23 Baseline N= 32 Financial Analysis Measurement Period = Patients with delayed discharge of 6 days 5 Patients with delayed discharge of 2 days o 3 Medicare o 1 Medicaid o 2 Managed Care o 1 Managed Medicaid o 3 Self pay o 1 Medicare o 1 BC/BS o 2 Managed Care o 1 Self pay Assumptions: $500 direct cost per day Baseline: 6 days x $500 = $3,000 x 10 patients = $30,000 estimated avoidable cost Measurement Period: 2 days x $ = $1,000 x 5 patients = 24 $5,000 estimated avoidable cost 8

9 Impact to BHCS Cost of maintaining current process (DO NOTHING!) Increase length of stay Negative impact on readmission Negative impact on quality of care Cost of spreading across BUMC $59,000 to educate 1700 BUMC nurses Benefits of spread Increase quality of care Reduce length of stay Reduce readmissions Reduce cost 25 Impact to BHCS Aligned with the Behavioral Intervention Team project to be implemented at BUMC Supports Vision 2015 Opportunity to explore role of other disciplines Use of 360 Pulse to identify patients with depression Spread of information providers and other disciplines Review charts of patients diagnosed with delirium History of behavioral health Behavioral meds continued on admission or resumed 26 To ignore the evidence, and hope that it cannot be true, is more an evidence of mental illness ~William Blasé 27 9

Antidepressants. Dr Malek Zihlif

Antidepressants. Dr Malek Zihlif Antidepressants The optimal use of antidepressant required a clear understanding of their mechanism of action, pharmacokinetics, potential drug interaction and the deferential diagnosis of psychiatric