Mental Health Association of Portland



Unity Transitions of Care (ToC) Workgroup

Meeting Minutes

Date: April 6, 2016

Present: Chris Farentinos, Ann Kasper, Patricia TenEyck, Becky Wilkinson, Sarah Ream, Courtney Woodward, Barb Snow, Alison Noice, Jennee Edwards,

Karissa Smith, Ben Solheim, Lindsay MacLean, Julie Oyemaja, Naiyana Cruz, Nirmala Dhar, Ben Solheim, Rod Estes, Jerry Garcia, Bill Osborne,

Sarah Hatch, Barb Snow, Divarshi Bajpai, Rick Ralston, Kelsey Tuttle, Rick Ralston

Guests: Maureen Bradley and guest

Next Meeting: May 4, 12:00-1:30 pm but only for participants in the 3 sub-groups

| Subject |Discussion |Action |Responsible |

|Purpose of this group |Today will be primarily to develop a context for the work to be done. |See attached PowerPoint slides | |

|Architecture plans |Architectural plans of each floor, including the Psychiatric Emergency Services (PES) on the first floor, were reviewed. A lot of | | |

| |thought was put into the architecture plans and design of the environment to give a feeling of hope and recovery | | |

| |First floor, main area: Entrances for walk-ins and ambulances. Triage rooms close to the entrance so an immediate triage assessment | | |

| |can be completed. A couple of the triage rooms can be converted into Hold rooms when needed. There will be space for Peer Support | | |

| |Specialists, community organizations co-located at Unity, a room for court hearings, a meditation/spiritual room. | | |

| |In the PES on the 1st floor will be a “Living Room” which will be for lower acuity patients getting ready for discharge. Another | | |

| |portion of the PES will be for more acute patients which will have calming rooms | | |

| |1st floor also has two Inpatient units for lower acuity patients | | |

| |2nd and 5th floors: Inpatient units for higher acuity patients | | |

| |6th floor: kid’s floor. Have an in-house school. | | |

| |Nurse stations on all floors will not be closed in. | | |

| |Unity will be able to serve bariatric patients | | |

|Answers to questions from | What will be the selection process for choosing which organizations will be co-located at Unity? | | |

|last session |A: The process will be an agreed upon by all. Most organizations will be doing In-reach rather than having staff based at Unity. | | |

| |Will figure out who needs to be there all the time. | | |

| |What will be the role of community based organizations not located at Unity? | | |

| |A: They will continue to be partners with Unity, as they are currently with hospitals. | | |

| |Will there be financial support for co-location? | | |

| |A: No. Unity will provide the space but does not have funds to pay for co-locating organizations. | | |

| |Will there be Interpreter services? | | |

| |A: Yes | | |

| |The group asked for an inventory of resources? | | |

| |A: Not sure what this was about. | | |

| |What will be the process for warm handoffs? | | |

| |A: We will figure it out together | | |

| |What will be the role of Peer Support Specialists? | | |

| |A: Legacy will be hiring peers who will work in the PES. They have a key role in the PES. Are also working to get support to hire | | |

| |Peer Support Specialists who could work in the community, especially for patients with high utilization. | | |

|DRAFT Unity Medical |These are still in draft form. They will be finalized when Greg Miller, MD, the new Chief Medical Officer, starts in June. However, |See attached, slides 18-22. | All |

|Stability and Admissions |they give a good overview of the medical stability and admissions criteria. |Please do not distribute these to | |

|Criteria | |others who might assume they are | |

| | |final. | |

|Review of last session’s |Briefly reviewed the workplan that was developed at last month’s Transitions of Care meeting. |See attached | |

|work |Section 1 relates to Co-location | | |

| |Section 2 relates to In-Reach: will develop an algorithm showing what the flow will be | | |

| |Section 3 relates to Coordinated Referrals | | |

| |Input from Group regarding next steps | | |

| |Create small subject matter expert workgroups to do much of the work | | |

| |Address cultural needs. Need staff addressing cultural needs who really understand needs in specific areas (EDs, inpatient units) | | |

| |Unity’s connection to primary care is important. Will need to work on this flow. How to create strong coordination between the PES | | |

| |and primary care medical homes of patients. Currently, transitions to primary care medical homes are stronger than transitions to | | |

| |mental health homes. | | |

|Next Steps -- Sub-groups |Three sub-groups were formed which will all meet during the regularly scheduled Transitions of Care meeting time May 4, 12:00-1:30 but| | |

|to work on tasks |will split up into the three sub-groups to work through tasks for their areas. | | |

| |See bottom of Minutes for sub-group members. | | |

| |Subgroup 1 – Inpatient Discharge Process: Intensive Transition Team, Columbia Care, Lifeworks Rapid Response, peer | | |

| |Subgroup 2 – PES Discharge Process. Cascadia ED divert, Legacy Crisis Intervention Specialist, Adventist ED social worker, peer | | |

| |Subgroup 3 -- Flow for Peer Support Specialists, Outreach and Community Outreach/Health Workers in PES: NAMI, Outreach and Community | | |

| |Health Worker, DePaul ED Outreach Worker, Emanuel ED Outreach Worker, Mental Health America of OR, Youth Move of Oregon | | |

|Roundtable Updates | | | |

| |NAMI Walk is May 15 | | |

| |State of OR, Older Adults BH: Nirmala recommended we have sub-group in the future to address the needs of older adults | | |

| |Cedar Hills has partnered with Western Psych. Are also working on opening a DUII service. | | |

| |Emanuel ED: Becky has been doing a social work internship with Sarah Reams. Emanuel has day shift 7 days/wk, 7:30-4:00 pm and evening | | |

| |shift 3:00-11:30 pm | | |

| |DePaul: Hired an ED Outreach Worker, Erica Edwards | | |

| |Columbia Care: Just opened Powell Butte housing under a Mult Co contract. Are working on developing ICM program for high utilizers. | | |

| |Staff will have caseloads of 15 | | |

| |Youth Move of Oregon: They are a Statewide non-profit, serve ages 14-25. Provide peer support and wrap around services | | |

| |Mult Co ICP (Involuntary Commitment): Working with Legacy to implement a process so the ICP Investigators meeting with patients on | | |

| |Hospital Holds will be able to document in Legacy’s Epic computer system. | | |

| |FamilyCare: Lots of recent media attention but they’re doing fine | | |

| |CODA: Have opened a centralized Intake line (855-CODA). Now have medication assisted treatment in several locations | | |

| |Mental Health American of Oregon: Got authorization to have a Peer Support Specialist at Emanuel’s ED. Also have a Peer Support | | |

| |Specialist at Good Sam’s ED. Will have Project Nurture at Prov Milwaukie. Have new Peer Support Specialist for IMPACT team (Team of| | |

| |specialists in addictions who do brief intervention and outreach to patients admitted on medical floor but with primary addition | | |

| |diagnosis) | | |

| |Project Respond: Are hiring 2nd Peer Wellness Specialist for crisis team. |Rick will distribute this |Rick |

| | |information on CODA to Legacy care| |

| | |mgmt staff | |

| | | | |

| | | | |

|Next Steps |Will cancel the next regularly scheduled meeting May 4 and in its place, Rick will send separate mtg invites for the sub-group participants. Will use the same room but | Rick |

| |split up into the 3 sub-groups | |

| |This Transitions of Care workgroup will continue meeting following Unity opening even though the format may change. | |

| |In June mtg: | |

| |>Will present the work accomplished in the May mtg by the sub-groups | |

| |>Show Unity Transportation algorithm noting what location patients will be taken | |

R/PM/Unity/ToC/ToC Unity mtg 04 06 16

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