What is the problem that needs to be addressed? Please describe how it is related to mental health.
There are three major issues with mental healthcare in Orange County: 1) Doctors are not incentivized to provide better care (Pay for Performance) and 2) Care isn’t provided in a Patient-Centered Medical Home (https://pcmh.ahrq.gov/page/defining-pcmh) 3) Discharge Planning for Psych in Orange County needs improvement.
Why is this a concern for Orange County? What can Orange County and other counties learn from this project?
It is assumed that Orange County wants to purchase healthcare services driven by quality with efficiency. Other counties can learn how motivating doctors can create system change.
What is currently being done to resolve this problem in our county and throughout the United States? If applicable: Is it working; why or why not?
In Psych, Fee for service. In Cardiology, the Centers for Medicare and Medicaid (CMS) identified 30-day readmission for Heart Failure as a metric identifying quality. In response, the Cardiologists spent a little bit of time yelling & screaming in private. In public, the American Heart Association and other stakeholders created Target:HF (https://www.heart.org/en/professional/quality-improvement/target-heart-failure/strategies-and-clinical-tools) and doctors became highly motivated to provide better care. The readmissions checklist identifies multiple reasons for readmission for Heart Failure that can be applied to psychiatry. Target:HF also has a Discharge Planning tool/checklist and a phone followup script/checklist. NAMI punted their discharge planning checklist to a little known organization from Oregon and that discharge planning tool/checklist needs improvement. In psych, stovepiped specialty at an isolated facility. In Pediatrics since 1967, the Patient-Centered Medical Home – a single location to get all care with cross-disciplined care teams. It is well known that psych patients have a triad of psych-infectious disease-substance abuse. Psych doctors are trained to do Psych. They are not trained to manage Syphilis, HIV, Human Papilloma Virus, etc. So psych patients are routinely admitted to psych facilities with untreated Syphilis/HIV/HPV etc and these patients have no pathway to followup via a checklist to bring to the doctor that will provide the care psych is deficient in. Furthermore, Psych drugs induce/inhibit the most common cytochrome P450 CYP enzymes that yield medical drugs ineffective. So what happens, for example, is psych patients with HIV get admitted to Psych wards then can be not treated for HIV or get dispensed HIV drugs whose efficacy is decreased by the psych drugs prescribed. Technically the jury is out on whether a patient in a psych ward with untreated HIV or erroneous treatment for HIV suffers increased rates of morbidity or mortality because conducting such a study is unethical (we don’t randomize patients to suboptimal care to see what happens compared to patients given optimal care). It is clear that Orange County isn’t collecting those metrics for this one example. There are likely many, many other possible examples in people with autoimmune disease, heart disease, etc.
What is new or different about this project idea? Please describe how this differs from what is already being done (Question 6). Please list any research that was done on this topic.
Doing it as opposed to what is already being done which is not addressing the team based errors that are common in medicine.
What is the project idea? Please describe how this project will operate.
1) Decrease/suspend payment to facilities/providers that have 1 year readmission issues for Psych Patients. 2) Create a Patient Centered Medical Home with a minimum of a Board Certified Psychiatrist, Board Certified Internal Medicine Doctor, Board Certified Infectious Disease Doctor, and Board Certified Clinical Pharmacist. These are the docs that need to know each others medical records so it makes sense to put them in the same place so they are not faxing/e-sending their records between incompatible systems with the associated lag times that delays care and slows things down. You can even get docs dual board certified in Internal Medicine-Psych, Family Medicine-Psych or even triple boarded in Psych-Pediatrics-Child/Adolescent Psych. 3) Consider other never event / quality metrics that will align a patient’s outcome with the provider’s compensation. 4) Create a discharge planning tool/checklist that is evidence-based and tied to compensation.
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