AMA from Detox Learning Collaborative

Transcription

1 January 25, 2013 BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

2 Agenda 1. Introductions 2. Overview of the project Western NY Medicaid Fee for Service (FFS) Data Analysis 4. Highlights from the literature 5. Discussion regarding next steps and data needs BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

3 State Priority Area: Improve Care Coordination for Individuals in Inpatient Detox Programs 1. Develop a Learning Collaborative with Regional Detox Providers A. Invite Providers B. Invite a past consumer of service to participate in the discussion C. Focus groups of current patients 2. Discuss what we both know and don t know about detox issues. A. Integrate insight from the literature B. Develop a plan that will answer questions and assure clarity of OASAS regulations, types of detox admissions and related level of care criteria 3. Obtain perspectives on the issue from Detox Unit staff 4. Design a group process that will lead to focused conversation on the root cause of the problem(s) along with the opportunity to creatively brainstorm solutions 5. Work with the GNYHA/HANYS/OMH Reducing Readmissions Quality Collaborative to learn and share information in a manner that is consistent with their current processes BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

4 State Priority Area: Improve Care Coordination for Individuals in Inpatient Detox Programs, Cont. 1. Develop a set of recommendations to address the Detox challenge and share with other Detox Service stakeholders the Detox challenge 2. Based upon feedback, design a model to address the challenges and identify program(s) willing to pilot 3. Develop a method to track implementation 4. Implement pilot, track results and report out after 3 months BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

5 Discussion with OASAS 1. November 6, 2012 call 2. Steve Kipnis, MD OASAS Med Dir and Rob Piclell, LMSW Office of Med Dir 3. Reviewed the plans for the Learning Collaborative A. Enthusiastic support for the project B. No requirement for IRB C. Standard Consent is adequate to allow us to meet with patients with provider s approval D. Request for periodic updates BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

6 Western NY Regional Medicaid FFS Data total Detox discharges, 18% were AMA 2. By Day of week A. 27% admitted weekend (F-Sun) and 73% weekday (Mon-Th) B. 41% D/C weekend and 59% weekday 3. 3 left on a holiday (5%) 4. D/C by quarter A. 42% Jan-March B. 19% April-June C. 14% July-Sept D. 24 % Oct-Dec E. 66% Oct-March 5. For LOS =1, admission day of the week: 45% on Thursday, 25% Tuesday, 10% Wednesday, 5% each Su/M/Sa BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

7 Gender and Race BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

8 Drug of Choice Valid Frequency Valid Cumulative Alcohol Use Cannabis Use Cocaine Use Opioid Use Substance Use Unknown Total DiagnosisCategory * RaceName Crosstabulation RaceName DiagnosisCategory Total Alcohol Use Cannabis Use Cocaine Use Opioid Use Substance Use Unknown Black (Non- Hispanic) Hispanic Unknown White (Non- Hispanic) Count % within RaceName 70.6% 40.0% 100.0% 33.3% 49.2% Count % within RaceName 0.0% 0.0% 0.0% 3.0% 1.7% Count % within RaceName 5.9% 0.0% 0.0% 12.1% 8.5% Count % within RaceName 17.6% 60.0% 0.0% 42.4% 33.9% Count % within RaceName 0.0% 0.0% 0.0% 3.0% 1.7% Count % within RaceName 5.9% 0.0% 0.0% 6.1% 5.1% Count % within RaceName 100.0% 100.0% 100.0% 100.0% 100.0% Total BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

9 Age and County of Origin Valid Frequency Valid Cumulative Total County Valid Frequency Valid Cumulative Allegany Broome Erie Genesee Monroe Niagara Orleans Steuben Total BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

10 Length of Stay (los) Valid Frequency Valid Cumulative Total LOS for all Statistics N Mean Median Range Minimum Maximum LOS Valid 59 Missing BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

11 LOS Broken Down by Substance DiagnosisCategory LOS Total Alcohol Use Cannabis Use Cocaine Use Opioid Use Substance Use Unknown Count % within 24.1% 100.0% 0.0% 45.0% 0.0% 100.0% 33.9% DiagnosisCategory Count % within 13.8% 0.0% 40.0% 15.0% 0.0% 0.0% 15.3% DiagnosisCategory Count % within 27.6% 0.0% 40.0% 5.0% 100.0% 0.0% 20.3% DiagnosisCategory Count % within 6.9% 0.0% 0.0% 15.0% 0.0% 0.0% 8.5% DiagnosisCategory Count % within 13.8% 0.0% 20.0% 0.0% 0.0% 0.0% 8.5% DiagnosisCategory Count % within 3.4% 0.0% 0.0% 10.0% 0.0% 0.0% 5.1% DiagnosisCategory Count % within 6.9% 0.0% 0.0% 10.0% 0.0% 0.0% 6.8% DiagnosisCategory Count % within 3.4% 0.0% 0.0% 0.0% 0.0% 0.0% 1.7% DiagnosisCategory Count % within DiagnosisCategory 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Total BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

12 LOS by Substance LOS for individuals with Alcohol Dx N Mean Median Range Minimum Maximum LOS Statistics Valid 29 Missing LOS for individuals with Cannabis Dx N Mean Median Range Minimum Maximum LOS Statistics Valid 1 Missing BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

13 LOS by Substance LOS - Cocaine N Mean Median Range Minimum Maximum LOS Statistics Valid 5 Missing LOS - Opioid N Mean Median Range Minimum Maximum LOS Statistics Valid 20 Missing BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

14 LOS by Unspecified Substance LOS - other drug Statistics N Mean Median Range Minimum Maximum LOS Valid 1 Missing LOS - Unknown N Mean Median Range Minimum Maximum LOS Statistics Valid 3 Missing BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

15 Housing Valid Frequency Valid Cumulative Homeless - Shelter Homeless - Street Mental Health Community Residence Private Home or Apartment SUD Inpatient Rehabilitation Unknown Housing Total HousingatDischarge Valid Frequency Valid Cumulative Homeless - Shelter Homeless - Street NULL Private Home or Apartment SUD Inpatient Rehabilitation Total BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

16 Axis I Diagnosis $AllAxisIDx Frequencies All Axis I Dx a N Responses of Cases Amphetamine Withdrawal 6 5.6% 10.2% Alcohol Intoxication 8 7.5% 13.6% Opioid Dependence % 37.3% Alcohol Abuse 1.9% 1.7% Alcohol Induced Mood Disorder 1.9% 1.7% Schizoaffective Disorder 2 1.9% 3.4% Major Depressive Disorder, Recurrent, Unspecified 2 1.9% 3.4% Bipolar Disorder NOS 1.9% 1.7% Alcohol Dependence % 42.4% Cocaine Dependence % 25.4% Cannabis Dependence 5 4.7% 8.5% Inhalant Dependence 1.9% 1.7% Nicotine Dependence 5 4.7% 8.5% Cannabis Abuse 1.9% 1.7% Sedative, Hypnotic or Anxiolytic Abuse 5 4.7% 8.5% Opioid Abuse 2 1.9% 3.4% Cocaine Abuse 2 1.9% 3.4% Diagnosis Deferred 3 2.8% 5.1% Total % 181.4% BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

17 Axis II DSMAxis21 Frequency Valid Cumulative Valid Other Unknown DSMAxis22 Frequency Valid Cumulative Valid blank BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

18 Axis III Valid DSMAxis31 Frequency Valid Cumulative diabetes glaucoma unspecified asthma with COPD asthma alcoholic hepatitis hepatitis C seizure disorder adult antisocial behavior Total Missing Total DSMAxis32 Valid Frequency Valid Cumulative unspecified asthma hepatitis C allergic arthritis disc disorder seizure disorder Total Missing Total BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

19 Dual Diagnosis DualDx Valid Frequency Valid Cumulative No Yes Total ThreePlusDetox Valid Frequency Valid Cumulative No Yes NULL Total BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

20 Highlights from the literature 1. OASAS 2012 Outcomes Dashboard Mission Outcomes: A. Metric 4: increase availability of culturally competent, recovery oriented care B. Metric 5: increase program oversight to ensure culturally competent, quality services C. Metric 7: increase use of Outcomes Measures to hold providers accountable 2. I m Going Home : Discharges Against Medical Advice A. Predictors of AMA discharge: lower SEC, male, young, Medicaid or no insurance, substance abuse, lack of PCP, financial issues, sickness within the family, personal or family obligations, feeling better, receipt of social assistance payment B. Psychiatric interventions to reduce AMA D/C: nurse as patient advocate, evaluating for MH issues early in admission, identify patient expectations re the admission early on C. Strategies for preventing AMA D/C: address substance withdrawal (Nicotine, other), recognize psychological factors (anger/anxiety possibly masking feelings of helplessness, AMA threat masking anxiety/anger/depression, missed opportunity for empathic intervention), motivational interviewing D. Use of Informed Consent and follow up plan BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

21 Highlights from the literature 1. being younger, having a shorter history of cocaine abuse, being admitted on a Friday and being an opiate dependent patient treated with clonidine only during the detoxification, were significantly associated with leaving AMA. 2. AMA patients fail to access residential or outpatient treatment needed after detoxification and often return to detoxification treatment multiple times which has deleterious results for the patient and is taxing to the healthcare system 3. AMA patients reported drug use did not impair their health, were injection drug users, younger and had fewer previous treatment admissions. AMA patients were more likely to be unemployed and report that drug use did not impair their health 4. Suboxone treatment decreased premature termination of opioid detoxification completion when compared with clonidine. 5. Patients in the UPD group were younger on admission, had higher Alcohol Problems Questionnaire scores, had started to drink heavily at a younger age, were more likely to have previously used cocaine, amphetamines and heroin, and to have smoked cannabis in the 30 days prior to admission. They were more likely to be positive for markers of hepatitis C infection, to have a borderline personality disorder, antisocial personality disorder, or to have concurrent opiate or benzodiazepine dependence. PD was associated with depressive disorder BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

22 Highlights from the literature 1. Discharge AMA was also more likely to occur on weekends (AOR = 2.27, 95% CI: ) and on days when social assistance payments were issued 2. Discharge against medical advice was most commonly predicted by patient factors, such as young age; single marital status; male gender; comorbid diagnosis of personality or substance use disorders; pessimistic attitudes toward treatment; antisocial, aggressive, or disruptive behavior; and history of numerous hospitalizations ending in discharges against medical advice. It was also predicted by provider variables, such as failure to orient patients to hospitalization and failure to establish a supportive provider-patient relationship, and by temporal variables, such as evening and night shifts. 3. patients who were admitted to the hospital "unscheduled" had a disproportionately higher incidence of subsequent AMA (against medical advice) discharge, particularly if they were alcoholic. This finding calls into question the cost-effectiveness of hospitalization as an initial treatment strategy for substance abusers who enter treatment impulsively and points out the need for additional study to determine the most cost-effective treatments for addicts whose primary motivation for treatment may be to obtain relief from precipitating stressors 4. the majority of the patients left AMA for personal reasons BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

23 Highlights from the literature 1. Comorbid medical diagnosis reduced the risk of AMA discharge by one quarter, whereas court referral to treatment reduced the risk by one half. A college education, vocational or other training, being employed, and having a history of previous AMA discharges significantly increased the risk. The most common reasons for AMA discharge, as perceived by treatment providers, were psychosocial problems, difficulties in the treatment program, and lack of interest in treatment. 2. Predictors of AMA discharge, based primarily on retrospective cohort studies, tended to be younger age, Medicaid or no insurance, male sex, and current or a history of substance or alcohol abuse. Interventions to reduce the rate of AMA discharges have not been systematically studied 3. Patients discharged AMA were more likely to be homeless and have multiple co-morbid conditions. At one year follow-up, the AMA group had higher readmission rates, was predisposed to multiple readmissions and had higher in-hospital mortality. Interventions to reduce discharges AMA in high-risk groups need to be developed and tested. 4. Reasons for and Correlates of Withdrawal of Consent and Discharge Against Medical Advice: Impaired doctor-patient communication, Lack of a primary care physician, Cognitive impairment, Mental illness, Current or past substance abuse (including alcohol), Terminal illness, Young age, Family and financial concerns, Living alone, Being male, Lower socioeconomic status, Medicaid or no insurance BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

24 Highlights from the literature 1. A standardized form for AMA discharges, including patient's understanding of the diagnosis, treatment, alternative therapies, consequences of refusing treatment and stated reasons for leaving against medical advice, might be of benefit to patients, physicians and hospital managers. 2. Optimize patient-centered communication 3. Due to the higher risk of adverse outcomes, hospitals should target AMA patients for post-discharge interventions, such as phone follow-up, home visits, or mental health counseling to improve outcomes. BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,

25 Discussion 1. AMA D/C from your perspective A. Reasons for leaving AMA B. Interventions currently in place C. Brainstorm new interventions to pilot 2. Data analysis: what else should we look at? What other data should be collected? 3. Other providers to invite? Consumers of detox services to invite? 4. Involvement of staff in the discussion? Involvement of current patients? A. Schedule times to meet on site B. Release of Information in place 5. Next steps? Face-to-face vs. teleconference call? BEACON HEALTH STRATEGIES beaconhealthstrategies.com February 22,