Morbidity and Mortality Meetings: The community feedback period for this idea began on 7/2/2019 and will end on 8/31/2019

What is the problem that needs to be addressed? Please describe how it is related to mental health.
Based upon the public reporting of Mental Illness/Homeless issues (https://www.ocregister.com/2018/12/19/234-homeless-people-who-have-died-in-orange-county-will-be-remembered-at-these-2018-memorial-services/ https://www.ocregister.com/2017/02/07/orange-county-homeless-deaths-hit-all-time-high/ https://www.nbclosangeles.com/news/local/OC-Sheriff-People-Who-Died-in-2018-Were-Homeless-506368791.html), there doesn’t seem to be a regional Morbidity and Mortality (M&M) meeting/conference (https://psnet.ahrq.gov/resources/resource/17043/Psychiatry-morbidity-and-mortality-rounds-implementation-and-impact https://psnet.ahrq.gov/search?topic=Journal-Article&f_resource_typeID=68&pageSize=50&f_topicIDs=628,308 https://www.sciencedirect.com/science/article/pii/S0924933817324513 https://www.psychiatrictimes.com/novel-approach-morbidity-and-mortality-analysis-psychiatry-residency). M&M conferences serve as an important feedback mechanism for providers to learn from the patients who experienced iatrogenic health decline or death. Because of the structure of Cal-Optima’s payer network and Orange County’s patchwork of homeless/mental health service contracts, a Patient-Centered Medical Home does not exist. Thus, when a person experiences significant morbidity or mortality the causes of that morbidity or mortality are not shared among the people that have provided services to that person. The feedback loop is missing for the vast majority of service providers in Orange County, CA that serve mentally ill or homeless individuals.

Why is this a concern for Orange County? What can Orange County and other counties learn from this project?
Knowing what causes morbidity and mortality is important. Sharing that knowledge with the people providing services involved in morbidity and mortality is important. Orange County, CA tends not to share information among its contractors, leaders, and citizens. County contracts specifically forbid publishing results in peer-reviewed or other journals to share information. This is a platform project – meaning the platform isn’t novel, but having the platform provides numerous advantages and learning opportunities.

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?
Morbidity and Mortality conferences have a long history in the surgical and procedural medical specialties. M&M conferences for psychiatry are a new entry in the past decade.

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.
M&M conferences tend to occur within one referral network (i.e. Hoag hospital has an M&M conference for its surgical teams, but Hoag doesn’t likely share that M&M conference with Kaiser Permanente). The way Psychiatric and Homeless services are structured in Orange County means that a meaningful referral network doesn’t exist and therefore the meaningful feedback of M&M doesn’t get shared with the numerous providers providing services. The structure of the ideal M&M would include peer specialists/mentors/leads, wrap-around service providers, the 13+ facilities operating Psychiatric facilities in Orange County, homeless service providers, Churches, etc. This is the consequence of the lack of an Accountable Care Organization (ACO) within one referral network serving the population experiencing Mental Health/Homelessness.

What is the project idea? Please describe how this project will operate.
Put in the legal/incentive infrastructure to get the service providers – including cross-referral network providers, peer specialists, Churches, Wrap Around Service Providers, etc – for homeless/mentally ill patient populations into a monthly Morbidity and Mortality conference. The Morbidities and Mortalities discovered over the past month will be reviewed during the conference, including medical record review and presentations by the providers who served the person who experienced the Morbidity/Mortality. Ideally, autopsy results would be shared to provide feedback on what was missed (i.e. a Rabies diagnosis). Train the para-professionals (i.e. homeless service providers, peer-specialists, Churches, etc) on the high-risk warning signs for morbidity and mortality (i.e. wounds that don’t heal, signs of Syphilis, bloody diarrhea, dehydration, stroke, heart attack, bone/joint fractures, etc). Many of the diseases behind these high-risk warning signs may not have a provider in Orange County, CA willing to treat the underlying disease due to the likelihood that the treatment will cause greater M&M than not treating. In such a case the person experiencing the disease should be fast-tracked to SSI/SSDI/hospice and the appropriate resources be made available for the person to have a sense of end of life dignity.

Additional Information:
Respondent skipped this question

June 18, 2019

2 comments

Thank you for your submission. The innovation team needs additional information to explore this proposed idea. Please elaborate on your responses as best as possible so that we may work through our review process.

•Would the Innovative aspect of this idea be the multi-disciplinary and cross- system staff participation in these morbidity and mortality meetings?

The Patient Centered Medical Home (PCMH), while a nice term that many seem to understand, involves quite a few components. On the back end of a PCMH, licensed medical providers have many advantages to share information. Morbidity and Mortality conferences are one such example. After the Innovation Team’s response to the Improving Patient Care project proposal it became important to this submitter to break out as many of the PCMH functions that aren’t obvious so that people can understand more than the buzz-word and can make choices. Take the whole PCMH or take a few parts of one. There isn’t an obvious strategy with the current state of reality: separate but equal facilities for a Psychiatric PCMH isn’t likely to bring quality; keeping multiple referral systems for a single patient is a pain that doesn’t foster quality either.

This submitter agrees with Abraham Flexner (http://archive.carnegiefoundation.org/pdfs/elibrary/Carnegie_Flexner_Report.pdf) that learning from actual cases in a medical setting is better than learning from a canned textbook chapter in a classroom. Prop 63 Innovations funds are for learning. The canned textbook chapter for mental illness is a story about initial stabilizing treatment, downward drift and early death – the canned textbook chapter for any not-well-understood disease. Unfortunately, its not likely that the people motivated and curious about mental illness (i.e. peers) will be making their way into leadership positions at Academic Medical Centers. The canned textbook chapter would cite early death as a limiting factor to influencing the future of healthcare. State medical boards would cite State statue/laws about licensing doctors with a mental illness. The only way to break away from the canned textbook chapter is to learn from actual medical cases.

This submitter is personally curious about Torsades de pointes (TdP)/Prolonged QT in mental health. In a population of approximately 150,000 people with serious mental illness, if you believe the textbook, TdP has very likely killed a few. How good did we get at patient selection for treatments that may lead to TdP? Or do we just accept that TdP will kill a certain percentage and just roll the dice? Can we recognize a case of TdP after it occurs? The first sentence of https://www.ncbi.nlm.nih.gov/pmc/articles/PMC419299/ describes exactly what we don’t have in Orange County. Studying mortality can be very informative as we can work backwards from causes of death to idiopathic/iatrogenic risk factors. The canned textbook chapter that reads initial stabilizing treatment, downward drift and early death describes idiopathic/iatrogenic healthcare.

Having a doctor/licensed provider get up in front of a community to explain their thought process prior to the death of a patient is quite a motivating force to do better. I am unaware of any Psychiatric M&M meeting in Orange County. Even if there is one, patients are shuffled between referral networks so frequently that the providers involved in care in the year prior
to morbidity or mortality are not likely to be at a proprietary M&M conference. With the introduction of mid-tier providers (i.e. Nurse Practitioners, Physicians Assistants, etc), it is unclear if M&M conferences include all the providers that were decision makers prior to a person’s death. Without an M&M a provider, at best, assumes the patient was lost to follow-up.

Health systems/payers/providers are moving into accountable care organizations (ACOs) and pay for performance models. This submitter sees Orange County moving in this direction where the Social Determinants of Health (https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health https://www.cdc.gov/socialdeterminants/index.htm https://www.who.int/social_determinants/en/ https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/) are starting to be considered healthcare. Since the Social Determinants of Health are now on the table, revisiting attitudes about outcomes is important. Having a psychiatric diagnosis, historically, is associated with bad outcomes. Separating a psychiatric diagnosis from Social Determinants of Health enables revisiting the bad outcomes to understand if it was the diagnosis that made a bad outcome or the Social Determinants of Health that made a bad outcome. What are people with mental illness dying from: cholera, E. coli, diabetes, etc?

The measure of innovation of an idea isn’t the submitter’s view, its what everyone else thinks too. Ask Cal-Optima what they think of the idea as they would be the payer most likely to benefit (or loose) from this idea. Ask University of California, Irvine Medical what they think of the idea as they are likely the referral network to have the most M&M conferences. If a Psych M&M conference exists in Orange County then it most likely would be at UCI. Ask a psychiatrist if they feel Cal-Optima, or more likely any other health insurance payer, would use such an M&M activity to penalize a psychiatrist. Again, this project proposal depends upon the safe-harbors described in https://policysearch.ama-assn.org/policyfinder/detail/error%20reporting?uri=%2FAMADoc%2FHOD.xml-0-2806.xml, so when you ask someone else make it clear that the activity would come with protection from discovery/excess penalty. Ask what scope of attendance would be tolerable (doctors, mid-tier providers, nurses, psych-techs, non-licensed peers, etc) and if offering non-disclosure agreements would change the tolerability answer.

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