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Medical Clearance Work Group MeetingWednesday, December 18th, 20198-9 a.m.Audio and Visual: Meeting Number: 805 605 477 Password: Wednesday18Audio Only: 1-650-479-3208 Access Code: 805 605 477AttendeesLaura Appel, Dr. Michael Brown, Dr. William Fales, Dr. Lia Gaggino, Krista Hausermann, Dr. Laura Hirshbein, Briana Jacob, Dr. Charles Koopman, Dr. Jennifer Peltzer-Jones, Dr. Debra Pinals, Selena Schmidt, Dr. Carmen Serpa, Chris Wojcik, Dr. Julie Yaroch, Carol Zuniga, Ashley Hill, Dr. Bill Sanders, Kristy Moore, Dr. Pamela Coffey, and Julie Szyska??????????????AgendaSummary of the 12/17 SMART/HII Collaborative meetingHolland Hospital SMART pilotHolland Hospital piloted SMART between June and November 2019 in partnership with the Robert Brown Crisis Center, Pine Rest, and Forest View.A control/baseline period of six months (December-June 2019) preceded the pilot period. There were significantly more patients during the pilot period than during the control/baseline period.Overall, the use of SMART was a success. It appeared to increase ED efficiency and decrease cost. Holland Hospital, the receiving facilities, and Ottawa County CMH have decided to continue using it.Five success metricsAverage length of stay in EDDecreased 9% overall for admitted patients (50 patients/month were admitted to the inpatient unit from the ED)No decrease for discharged patientsCharges for ED visitED-level charges, lab charges, radiology charges, evaluation chargesDecreased 26% on average$900 decrease per visitAdditional testing (on top of SMART) requested by psych. for medical clearanceRequested 2.9% of the timeRequested 4% of the time during the first three months of the pilot period and 1.8% during the last three months due to the learning curveReturns to the ED within 24 hoursNo increaseDuring the pilot period, there were five returns to the ED within 24 hoursAll five returned for issues that should have been captured/addressed in the initial ED assessmentIn-house transfers from the inpatient unit to the medical floor as a result of a medical issueNo increaseDuring the control period, there were three patientsDuring the pilot period, there were three patientsOne patient was transferred for medical reasonsMost important for success was how well the ER physicians filled out the form. When the form was filled out correctly, inpatient psych. liked the tool. At the beginning of the pilot period some doctors were checking the “no” boxes without reading the details.Physicians filled out the forms on paper. The electronic version was available for those wanting to view it.SMART does not address drug screening. While drug screening is not needed for medical clearance, it is important for the inpatient side. At Holland Hospital, the ED physicians were encouraged to carry out drug screening.Pine Rest Urgent Care SMARTThe SMART tool was implemented in August 2019 at Pine Rest Urgent Care. The largest challenge was translating something meant to be used in the ED into something that could be used in the urgent care setting (e.g. with individuals calling the urgent care center). The tool helped staff decide if patients needed to go to the ED. Anecdotally, patients seemed to like it because it helped them avoid going to the ED, which they viewed as holding pen. After a few months, both the intake workers and the inpatient side liked the tool.Pine Rest saw SMART as an objective tool that helped everyone and is ready to roll it out more widely.Social workers are becoming more comfortable with the tool.Pine Rest has also utilized HII, which has gone well.Psychiatrist perspective: “SMART ensures good evaluation of the patient. Anything standardized makes the process more efficient.”“The western part of the state will roll out SMART. This is a high-quality patient safety tool.” “We will probably over-test patients for a while and then slowly back down from that. It is a matter of educating.”Experience with implementation of clinical sobriety assessments [Hack's Impairment Index (HII)]The HII is used at Mercy Health because the legal alcohol limit for driving is not always an indicator of clinical sobriety. It has been used in conjunction with other testing. If the alcohol level is zero, the HII will not be used. It is not used with everyone but with those who are appropriate candidates. The tool is most useful with patients who are seasoned drinkers with a high tolerance for alcohol. HII is not useful with younger individuals drinking for the first time because the HII score may correlate with the alcohol level in these individuals.HII is a series of assessments similar to a roadside sobriety test. When the HII score is three or below, the individual is clinically sober enough for a psych. assessment.The legal alcohol limit is 0.8, but this limit is not clinically supported. Tolerance plays a large part in clinical sobriety, which is not the same for all people. In some cases, the psych. assessment can be carried out earlier based on clinical sobriety.HII is not currently being used as the standard at Mercy Health. Much baseline testing is still being used. Mercy Health hopes to integrate HII.Overall, HII is easy to use and reduced the time between arrival in the ED to assessment.Spectrum Health ED social workers have been using HII since September 2019. They would like to ensure that providers have a good understanding of it and are still working through education issues. Anecdotally, HII has decreased the length of stay in the ED. One issue has been with patients who are clinically sober but known to be suicidal. While they can pass the HII, they have a history of being suicidal.Work group comments on the 12/17 SMART/HII Collaborative meetingHospitals and EDs are best able to implement SMART. The CMH working with Pine Rest may need support if SMART is rolled out broadly (to urgent care centers, access centers, triage centers, etc.).Cost savings in the ED resulting from SMART implementation may shift to the receiving facilities.Savings may be seen if SMART implementation prevents lab work duplication.Soft launch – Dr. Fales and Dr. Pinals Beginning March 2, 2020Aiming for 90% of receiving facilities to accept MAPAG-SMART by September 1, 2020 Where should we begin?Kent County/HollandBuilding interestAnnouncing hospitals coming on boardMap and running list of groups that have bought into MAPAG-SMART Champions within systems Implementation – Dr. Fales and Dr. PinalsRolling out and adopting MAPAG-SMART within health systemsTool kit tailored to all key partners: VideosDraft protocol and proceduresOther items to includeMAPAG-SMART FAQ document to ensure the form is filled out correctlyTraining materials (webinar)One-to-one trainings for staff who missed trainingOther thoughtsMandatory in-person trainingED director, receiving facility director, and other staff (physicians, nurses, social workers, and so on)A selling point for the MAPAG-SMART form is that the second page of MAPAG is standardized which may be appealing to receiving facilities. MAPAG and SMART have the same process and protocol.The medical clearance process should include both patients on the medical floor who are ready for discharge and patients in the EDs.CMHSPs should expect the medical clearance form in the medical packet that is sent to the receiving rmation to possibly include on the form:Neurological clearancePrimary care physicianReferring/screening physicianChecklist of behavioral symptoms affecting placementLab testing:Repeated testing when necessary (diabetic patients)CPK level (patients with schizophrenia)Drug screeningPregnancy testing of females of child-bearing ageSerum alcohol levelBlood sugar (diabetic patients)Lithium toxicity testing when applicableAscension has been holding work groups within its 15 hospitals to define medical clearanceConsidering rolling out SMART as a health system across its 15 hospitalsAscension Borgess Hospital in Kalamazoo has been receptiveWill be meeting just after the new year to discuss the hospitals that will be rolling out SMARTSelena Schmidt can report back to the medical clearance work groupIs open to adding MAPAGRegional rollout to address differences in the health systemsIdentify at least two champions per region (ED and receiving facility)Begin with region sixChampions: Dr. Phillip Stawski and Dr. Bill SandersIdentify receiving facilities willing to participate and then engage the Eds and CMHs which refer to those facilitiesConduct an in-person meeting on relevant topics with psychiatristsNetworking opportunityDr. Peltzer-Jones is willing to serve as a championFeedback/quality measuresTwo-foldForm functionality issuesExperiences with implementationSurvey link to be posted on Medical Clearance websiteOngoing support (following implementation of MAPAG-SMART)Continuing educationProblem solvingCheck-ins on implementation progressSystem to train new staff membersSupports must be in place prior to rolloutFollow-up calls – Krista Thank you Summary of points made Extending offer Next stepsContinue to provide data supporting MAPAG-SMARTMPHI will make the MAPAG-SMART form and instructions without the “draft” watermark available for use in the field and look into the cost savings data from the Dr. Seth ThomasDr. Fales, Dr. Pinals, Dr. Peltzer-Jones, and interested work group members will discuss starting a basic retrospective chart review to research the utility of the SMART form in different sites around the stateMPHI will include develop the toolkit/educational materials, arrange for continuing education credits, and include relevant data on the websiteLaura Appel, Dr. Pinals, and Dr. Fales will discuss MAPAG-SMART and possible incentives with Medicaid contactsDr. Pinals will possibly look into conducting a focus group with the inpatient sideMPHI will develop a brief, five-slide overview of MAPAG-SMART in addition to a more in-depth slide deckDr. Fales will ask State of Michigan contacts to send a recognition letter to those championing MAPAG-SMART and will look into a news release to recognize champions ................
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