At Baylor Scott & White Health’s academic medical center in Temple, Texas, the same patients kept coming into the emergency department (ED) for urgent as well as primary and specialty care. At the Temple facility, these high utilizer (HU) patients were responsible for 1.2% of admissions in 2018 and 3.9% of readmissions in 2018. The health care providers at the Temple facility recognized that breaking the cycle of readmissions could improve the quality of and support better and more appropriate utilization of services in the right setting.

To address high utilizers, the Temple facility launched the Complex Patient Management Team (CPMT), consisting of caregivers with expertise in internal medicine, psychiatry, case management, pharmacy, nursing and social work disciplines.

The methodology used empirical data to select a subset of patients quarterly. The CPMT analyzed variables and created patient-specific action plans that applied to all current and future encounters. The process consisted of six steps: goal setting, defining the target by identifying previous quarter HUs, sharing information using lists in Epic, discovering HU motivators, developing patient-specific action plans, and implementing the plan consistently across ED, outpatient and inpatient settings. The primary metric for evaluating success was ED visits and readmissions by high utilizer patients.

The key takeaway from the project showed that using a multidisciplinary team in action planning for high utilizer patients can reduce their use of ED services and lower admissions. A baseline cohort of the top 20 high utilizers from December 2018–February 2019 showed an 8% reduction in ED visits and readmissions in the three months prior to identification of the first intervention cohort. Results far exceeded the CPMT’s goal of reducing HU ED visits and readmissions by 30%. From March 2019–May 2021, the average reduction in combined ED visits and readmissions across subsequent cohorts was 35.7%. Importantly, 143 patients out of 202 total (71%) patients served by the CPMT had a decrease in readmissions.

This data was reported to hospital committees, a system-level improvement team and the governing board. With this data, the CMPT sees future opportunities to provide at-a-distance consultation and CME activities to spread best practice.

Oceans Behavioral Hospital Abilene provides inpatient and outpatient mental health care to adolescents, adults and seniors. The hospital serves the Abilene community and surrounding rural areas, filling a critical gap in the local health care continuum.

As part of an organization-wide quality improvement initiative in 2020, Oceans Abilene began collecting, analyzing and reporting data related to their use of the Patient Health Questionnaire (PHQ-9) to screen for and measure depression levels in patients. The PHQ-9 is a screening tool associated with the Joint Commission’s National Patient Safety Goal for Suicide Prevention. In addition to diagnosing and monitoring the severity of a patient’s depression, the PHQ-9 also screens for the presence and duration of suicidal ideation. The use of this tool has been essential in ensuring patients leave treatment better than when they entered while providing a much-needed standardized quality measure for behavioral health care, which lacks many of the empirical tools used in physical health care.

Beginning in July 2020, Oceans Abilene administered 1,086 questionnaires to patients over the course of a year. The assessment showed that 595 of those patients (55%) were experiencing severe depression symptomology at admission. While the dataset was formatted to screen out initial scores of minimal depression, notably, all of the screened patients in Q1 and Q2 of 2021 reported a severity level of at least moderate depression or above, and only 5% (53) characterized initial depression levels as mild in Q3 and Q4 of 2020.

Over the course of treatment, which averaged 9.91 days for all age groups, the average PHQ-9 score fell from 19.52 at admission to 3.67 at discharge – an 81% reduction in depression symptomology.

Additionally:

To ensure continued improvement in quality measurement and patient safety, PHQ-9 outcome information is reviewed by the medical staff's Quality Assessment and Performance Improvement Committee on a regular basis. Updates and suggestions for change are considered in the committee and then presented to the Governing Board for full approval.

In 2018, the Leadership Team and Quality Council of Peterson Health reviewed the publication Leading a Culture of Safety: A Blueprint for Success. This publication prompted Peterson Health’s ZERO Harm and Just Culture journey, and their first safety vision was created and approved by Peterson Health Leadership and medical staff.

The team identified the following goals for the project:

Within Peterson Health’s Just Culture, all workforce (clinical and nonclinical) are empowered and unafraid to voice concerns about threats to patient safety and workforce safety. While everyone is held accountable for actively disregarding protocols and procedures, the reporting of errors, lapses, near misses, and adverse events is not only encouraged, it is expected.

Their online event reporting system was revised to include an option for directors to select which behavior they identified in response to the event. This is done with the staff member to help them feel supported and held accountable at the same time.

The Zero Harm and Just Culture journey for Peterson Health has been effective in demonstrating both a reduction in harm and improved Culture of Safety. Their Culture of Safety survey results over the last several years have demonstrated a significant trend of improvement. When their journey began in 2018, their positive response rate related to a non-punitive response to error was at 60%. Improvement trended over the next three years to an all-time high of 90% in their FY 2021 survey results.

Patient Harm, as measured by the AHRQ PSI 90 measure, has also trended positively over the last three years. Harm rate per 1,000 discharges has decreased from 4.8 in FY 2019 to 1.3 in FY 2021. To this day, the entire organization continues to put Zero Harm and Just Culture at the forefront of everything they do.