Behavioral Health
Robust Behavioral Health Education Program and New Facility Offer Solutions to Patient and Staff Challenges, and Keys to Compassionate and Efficient Care The Startling Reality in Western North Carolina
Mission Health’s Behavioral Healthcare Strategy
Behavioral health is a stark and unrelenting issue in today's healthcare landscape. Like much of the country, western North Carolina is undergoing a true mental health crisis. The statistics are staggering: suicide rates in Mission Health System's western service area are four points higher than the state average. Regional jails report that an average of 58% of inmates are incarcerated primarily due to unmet behavioral health needs. 2016 data from North Carolina 211, an online resource for urgent, non-disaster help, shows that behavioral health and addiction services are the third highest need reported by callers. Furthermore, major depression was the most prevalent presenting psychiatric disorder in Mission regional hospital EDs in 2016. Regionally, the impact of depression on the workforce cost employers over $16 million annually.
As is the national trend, Mission Health is seeing an increase in all care settings in the complexity of patients presenting with co-occurring medical, psychiatric and substance use issues. Research from the Center for Disease Control (CDC) shows that much of this increasing complexity is due to patients experiencing significant personal trauma. Mission Health’s Behavioral Health staff understand that trauma is the most pervasive factor for behavioral health patients, especially those struggling with substance abuse issues. To address this complex crisis, Mission Health has adopted a new and advanced approach to healthcare called, Trauma Informed Care (TIC). With guidance from well-established research on the impact of trauma on personal health and behavior, Mission Health is reframing our approach to compassionate care by encouraging care givers to inquire about personal history and traumatic events as the first step in treatment.
Despite these challenging circumstances, there is growing recognition that providing appropriate and timely mental health care brings not just renewed hope and healing, but also a substantial return on investment. Every dollar spent on mental health programs results in three to five dollars in new economic contributions, in addition to years of healthy life. Ultimately, better mental health means a better bottom line for our communities, our economy and human wellbeing.
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Sonya Greck, MSN, RN, and Senior Vice President of Patient Safety Net Services and Behavioral Health relay the importance of moving ahead with this trauma informed care model for the sake of all Mission Health patients and clinical staff: “It’s not just about how we treat behavioral health patients, but how we treat all patients and our colleagues. We’re looking at a complete cultural shift within the hospital setting,” explains Greck. “The idea is to get out of judgmental, authoritarian care models of the past, and adopt a trauma-informed care model to gauge patient success and outcomes, thus informing how we work together with our patients.” This new model of care replaces the traditional provider-directed model with one that makes patient engagement central to treatment, explains Greck. “People are not broken; they come in with an illness they need to learn how to manage. In behavioral health, we aim to help them manage their illness. With that approach, a patient is empowered to take control of his health, and his quality of life improves.” Mission Health is not only committed to the behavioral health of our individual patients, but to improving the overall behavioral health of all those living in western NC. This population-based approach to mental health care aims to equalize health disparities across factors such as gender, race, socioeconomic class, and insurance structure, that exist in the region. This framework is consistent with Mission Health's commitment to integrated and patient-centered care throughout the institute. This commitment focuses on safety and efficiency during the entire patient experience, leading to more positive outcomes. Mission Health's Behavioral Health staff are wholly committed to minimizing patient stress by providing respectful, holistic and safe care.
“We’re looking at a complete cultural shift within the hospital setting. The idea is to get out of judgmental, authoritarian care models of the past, and adopt a traumainformed care model to gauge patient success and outcomes, informing how we work together with our patients.”
- Sonya Greck, MSN, RN Senior VP of Patient Safety Net Services and Behavioral Health, Mission Health
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The Vision for a Cutting-Edge Behavioral Health Facility For more information, see Appendix A. At this point, the demand for behavioral health services for western North Carolina residents far outweighs availability, and the region’s mental health crisis has created significant and persistent boarding challenges for Mission Health. Boarding refers to patient waiting time measured from arrival at the Emergency Department (ED) up to admittance for mental health services. This challenge highlights the need for a revamped treatment environment for behavioral health patients – an environment that is equipped with more space for patient care and staff education, and with innovative features to promote healing and hope. The biggest facility challenges Behavioral Health currently faces: • The age of the facility prevents full functionality or use by providers and patients. The necessary repairs list is overwhelming and facility replacement is the only practical solution. • The current design does not incorporate smart design knowledge for healing environments. For example, the best facilities have healing outdoor spaces, calming wall hues and art, and gentle lighting, rather than fluorescent lighting. • There is no dedicated space for Behavioral Health continuing education programs. It is of utmost importance that Behavioral Health department services are linked closely to the Emergency Department, as many behavioral health patients are funneled into care from the ED. Current facility challenges affect both patients and caregivers in the following ways: • The shortage of inpatient beds contributes to longer boarding times, which contribute to patient trauma and staff stress. • Given the increased numbers of patients with complex medical and psychiatric diagnoses, the need for a close connection between medical and psychiatric providers is growing. • Due to the decommissioning of St. Joseph’s Hospital building, current psychiatric units need a new home.
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Dr. Richard Zenn, Medical Director of Behavioral Health at Mission Health, confirms that closer ties between Behavioral Health and the Emergency Department promote excellent patient care. “It will be absolutely necessary for us to become even more closely tied to the ED especially because both departments are dealing with climbing rates of repeat patients, or ‘high utilizers.’ And while we need more beds, a hospital stay can sometimes be counter-therapeutic, so the issues are complex. Increased communication and work between departments will allow us to assess and better meet patient needs,” Zenn says, adding that tools like Crisis Prevention Intervention (CPI) will be important in the treatment landscape. “This strategic approach builds rapport with patients, empowering and involving them in treatment and recovery, while keeping patients and staff safe.” To successfully establish a Behavioral Health department based on this progressive approach, it must be programmatically, educationally, and environmentally supported via an expanded and strategically-designed treatment and education space. The time to invest in a comprehensive Behavioral Health Professional Development Program is now.
A first-rate facility should take these future needs into account; thus, the size and scope of the new facility considers projected growth of the region’s behavioral health service needs. Mission Health seeks an investor community committed to achieving our capital and programming goals.
Excellence in Behavioral Health Continuing Education For more information, see Appendix B. Along with an improved, state-of-the-art facility, Mission Health is invested in recruiting and retaining the most well-trained and highly competent behavioral health professionals, and supporting required or supplemental continuing education for these experts. This strategy contributes to enhanced patient care and better outcomes overall. Currently Mission lacks the structure for obtaining certified continuing education credits for multiple behavioral health professional licensure boards (LCSW, LPC, LMPT, etc.). There is no institutional support for non-licensed or Associate level licensed Behavioral Health clinicians wanting to grow professionally or attain a professional license. A high quality Behavioral Health staff needs access to continuing education, peer support, and streamlined certification attainment. The establishment of a comprehensive, institution-wide professional education program – like the existing professional development program for nursing staff – is a vital component of the future Behavioral Health department.
“Increased communication and work between departments will allow us to assess and better patient needs. This strategic approach builds rapport with patients, empowering and involving them in treatment and recovery, while keeping patients and staff safe.” – Dr. Richard Zenn, Medical Director of Behavioral Health, Mission Health Behavioral Health
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Currently Mission Health behavioral health staff have limited opportunities for in-house continuing education. The establishment of a Behavioral Health education program will not only benefit these professionals, but the patients whom they serve. Continuing education necessities for Behavioral Health include: • Diverse clinical skills programming, like Motivational Interviewing, Community Resiliency Model (CRM), Screening, Brief Intervention, and Referral to Treatment (SBIRT) for substance use, and cognitive behavioral therapy strategies for a variety of conditions • Self-care strategies to assist Behavioral Health care givers who are at risk of burnout from high-stress responsibilities • Opportunities for staff to professionally collaborate and connect • Staff opportunities to strengthen clinical competencies • Training in Trauma Informed Care (TIC) for every department at Mission Health, including the ED, as all departments treat patients with behavioral health and/or substance abuse issues • A full-time Behavioral Health educator to develop and teach curricula • Part-time support staff to oversee accreditations and plan events • Funds for program accreditation applications from multiple licensure boards, curriculum materials, etc. • Support for expansion of the staff training model to non-Mission organizations and external caregivers, ultimately assuring additional outside revenue and program sustainability
Existing local behavioral health education options are inadequate. While the Mountain Area Health Education Center (MAHEC) provides select offerings, they are limited and expensive, with an average daily cost of $150 per person. Linda K. Harrison, LPCS, CCS, MAC, private practitioner with Asheville Clinical Counseling and Behavioral Health Continuing Education Consultant for Mission Health, stresses that continuing education is a critical foundation for a solid and practical system-wide clinical presence. “We believe in bringing state-of-the-art training to our Behavioral Health staff with a strong emphasis on the integration of clinical skills that may be utilized the very next day in practice,” Harrison shares. “Behavioral health education is the next step in strengthening our programming and treatment for both inpatient and outpatient behavioral health and medical services.” For several reasons, supervisors are necessary to provide consistent support for this project. Since insurance reimbursements will likely be insufficient to cover Behavioral Health education, outside funding will be required for its success. Additionally, it’s imperative that the future Behavioral Health’s Professional Development Program resembles the successful program model the Nursing Department already has in place. A solid Behavioral Health program requires substantial investment and ground up work for success. Furthermore, if training is provided to Mission Health staff working outside of Behavioral Health, patient outcomes will improve system-wide.
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Providing TIC training to all Mission Health team members is the future goal explains Copestone Director Joe Frankovitch. “It’s especially important that surgery, oncology, and Emergency Department staff receive training, as so many of their patients experience high stress resulting from hospital stays. The elderly patient population is another faction that would benefit greatly from being treated by staff familiar with TIC,” notes Frankovitch. “In addition to these patient sectors, Behavioral Health would like to see TIC training rolled out to Mission Health’s Security and Psychiatric Evaluation Area (PEA), and eventually, external community service providers.” Educational opportunities will better prepare Behavioral Health staff members for the considerable demands of their work. And given the projected increase for the workforce in this quickly growing field, creating a program is wise strategic planning for Mission Health’s future. Continuing education and a new facility are the linchpins in improving Mission Health’s patient care efforts, collaborating with regional agencies, and preserving rank as a Top 15 Health System in the nation, as recognized by Truven Health Analytics. Simply put, it’s time to equalize the level of care for behavioral health patients and help heal every seen and unseen patient wound.
A new and enhanced Behavioral Health facility will dovetail perfectly with a strong Behavioral Health education program to fuel both the healthy growth of our professionals and the health system at large. The region’s need for services grows more urgent by the day. “We need the right space to provide the right services, as we strive to tie our educational programs to the cultural aspects of how we respond to the mental health needs of our community,” Greck expresses, while discussing a premier facility and educational programs for Behavioral Health staff. “It’s time for behavioral health to be a core component in the complete continuum of care.”
“We need the right space to provide the right services… It’s time for behavioral health to be a core component in the complete continuum of care.” – Sonya Greck, MSN, RN
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Appendix A. A New Behavioral Health Facility The New Behavioral Health Facility will provide a measurable solution to the current boarding issues in the ED. Unfortunately, patients in crisis may experience long stays in the ED while awaiting a bed in an inpatient psychiatric facility. Quantifying the problem highlights this severity: On average, Mission Health sees 35 boarding patients per day while waiting for inpatient placement. While patient treatment is provided by Mission Behavioral Health staff during boarding, this situation is far from ideal. The establishment of a new, properly equipped inpatient psychiatry facility with increased bed capacity (from 58 beds to 120 beds) will alleviate the current boarding crisis and move patients more quickly toward recovery and complete health. To describe the current Copestone Unit layout as archaic is not an exaggeration. The units are inadequate, unfurnished, uncomfortable and unwelcoming. There is not sufficient space for telehealth services, dedicated areas for group therapy and dining, or ample space for family interaction. The new, expanded and enhanced Behavioral Health facility will be equipped with features and amenities that fully support Trauma-Informed Care. Patients will benefit from outdoor space for activities and movement, and soothing rooms for practicing self-calming techniques. Adjustable lighting, calming sounds, music, aroma-therapy and soft surfaces will all contribute to the healing environment of the new facility. This enhanced environment will help staff and improve morale for patients in crisis. Patients will feel supported in their care on a fundamental level. Additional space will also allow for a better staff to patient ratio. Currently, the oject's completion, it will be 1:4. The department is ready to engage an staff to patient ratio is 1:6; after the pr architect and, after securing Board approval, aims to complete the schematic design for the space by the end of FY 2016.
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Appendix B. Clinical Education and Strengthening Clinician Competency There are more than 150 behavioral health professionals embedded in various departments throughout the health system. These professionals care for patients in hospital settings such as the Copestone Psychiatric Units; acute medical floors, like Heart and Trauma; and ambulatory settings, such as the Emergency Department, Primary Care, Mission Children’s Specialists and the SECU Cancer Center. Approximately 130 of these licensed Behavioral Health professionals are clinicians with master’s degrees or higher – yet another testament to Mission Health’s investment in providing superior patient care. Each of these providers must complete a minimum of 40 hours of continuing education every two years in order to renew their license. This requirement ensures that the excellent care they offer patients remains synonymous with the high standards for which Mission Health is known. In addition to maintaining their professional licensure, every behavioral health professional must attain proficiency for a defined range of core clinical competencies in order to fully serve behavioral health patients. A Mission Health work group composed of clinical leaders from diverse clinical settings across the entire health system established the clinical competency standards, and their findings were augmented by a system-wide survey of Behavioral Health clinicians. The five clinical competencies identified are: 1. Trauma Informed Care (TIC) Provision for Clinicians/Nurses • The TIC training approach focuses on understanding the neurological, biological, psychological and social effects of trauma. This therapeutic model is based on a collaborative, solution discovery process for the patient, as opposed to a directive approach that is less respectful to the patient. Training focuses on the tenets of TIC, which include transparency, safety, patient empowerment, peer support and collaboration, and a focus on resilience and recovery, as well as patient culture, history, and gender. • TIC training is especially necessary in pediatric units where recent trauma and cases of Post-Traumatic Stress Disorder are prominent, as well as for those patients battling substance abuse, which is often a coping mechanism resulting from past abuse and trauma. 2. Resiliency for Nursing Staff and Clinicians • Building resiliency is not only necessary for patients, but their caregivers, and centers around strong selfmanagement skills. To provide the best, ongoing care to their patients, caregivers must develop resiliency and solid self-care habits. While the road to resiliency varies for everyone, each staff member and clinician must identify and evaluate triggers (or motivators) that fuel reactive behavior patterns. The goal is to develop strong self-management skills, and incorporate strategies like grounding, developing self-empathy, and engaging with the community.
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3. Dialectical Behavioral Therapy (DBT) for Clinicians • This is a skills-based cognitive behavioral therapy model that emphasizes emotional regulation, relationships skills, and mindfulness, among other focuses. DBT has been shown to be particularly effective in treating personality disorders frequently encountered in the ED and Copestone, but it is also beneficial for a wide range of behavioral and relational issues. 4. Stages of Change and Motivational Interviewing for Clinicians • The Stages of Change model deals with the phases of patient readiness as they approach change, their willingness to employ strategies for change, and their attitudes about their issues and progress. • Motivational Interviewing is an approach to patient discussion that is empathetic and collaborative, designed to minimize negative confrontation, and deal effectively with resistance. It partners with the Stages of Change model, and the larger goal is to help patients prioritize and progress measurably. 5. Cognitive Behavioral Therapy for Insomnia (CBT-I) for Clinicians and Nurses • Good sleep is a pillar of high quality self-care. Behavioral Health is addressing the problem of insomnia, for example, which presents in all care settings and affects every population, age, and condition. A key goal of the department is to train caregivers across the entire health system on sleep issues. • CBT-I training is a method that uses no medication and has been proven to relieve insomnia in the majority of patients in the program. Fatigue, and especially chronic fatigue due to lack of sleep, affects outlook and impairs judgment; both are detrimental to emotional and physical healing.
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