A study on the effectiveness of the Stepped Care Model created to provide client support outside of the ACTT model dedicated to improving client outcomes was the focus of this presentation. The ACTT model bridges the gap between hospital in-patients with mental health challenges and their release outside of daily care; however, this program is often full. While in the ACTT model in a hospital facility, clients thrived, but they lost their support system after they were released and often required readmission. With each readmission, their prognosis declined.
Eight teams and six organizations in central eastern Ontario served 100 clients in the Stepped Care Model ACTT pilot program. This program operated without additional provincial or federal government funding. At the end of the program, 20% of patients in ACTT did not require full care, but needed some intervention to ensure their health did not decline.
A new model with one nurse responsible for providing modified activities and support for 20% of clients who required additional support (e.g. psychiatric intervention and community programs) on an as needed basis was piloted. At the end of the program, clients graduated; their graduation was linked to positive self-esteem. This modified Stepped Care Model opened 25 new positions across eight teams in central eastern Ontario.
From 2014-2017, 240 clients transferred to the new model; 11 patients were readmitted after graduating from the program, hospital stays were drastically reduced (544 admissions versus 109 admissions) and there was a 91% rate of client satisfaction.
Another study involving 301 clients was conducted at five sites in three distinct groups, Stepped Care clients, ACTT clients and clients who were discharged elsewhere (i.e. deceased, withdrawn, moved to another model). It reported on the following variables:
· Number of days in a hospital
· Client demographics
· Socioeconomic values
Findings from this study included:
· 98% of clients in the Stepped Care model stayed zero days in a hospital
· 83% of clients in the ACTT model stayed zero days in a hospital
· 86% of clients in other programs stayed zero days in a hospital
· Clients in the Stepped Care model were nine times more likely to spend zero days in a hospital than clients outside of the program
· Clients in the Stepped Care model were three times more likely to secure employment; they also faired better than their peers regarding addictions and psychosocial impact
In summary, the Stepped Care Model mitigates the need for hospital stays, and the additional level of support has proven to be more effective than the original ACTT model in terms of patient care.
Ontario Shores is a public hospital providing specialized assessment and treatment services to those living with complex and serious mental illness. It has been operating for almost 100 years, and changing an established culture has proved to be challenging.
Using restraint or seclusion (R&S) is difficult for patients and staff; it is also a human rights issue. R&S are considered treatment failures, and outside of the patient care norm. A clinical study monitored the following variables:
· Quality Improvement Plan (QIP), such as the length of stay using historical logs; the desired length of stay is 10 hours or less
· High visibility, immediate reporting and follow up procedures
· A strong recovery environment
Six core strategies were implemented:
1. Leadership – daily staff meetings regarding challenging patients
2. Sharing data with the team
3. Workforce development
4. Use of prevention tools, such as Dynamic Appraisal of Situational Aggression (DASA), to assess the likelihood that a patient/client will become aggressive within a psychiatric in-patient environment and alternatives to restraints
5. Consumer roles in in-patient settings to ensure the patient’s voice was heard
6. Debriefs within each report
Status reports were issued at 9:00 a.m. and 9:00 p.m. every day. Any incidence of R&S triggered an email notice to several groups, including shift managers, senior leaders and directors to reintroduce the patient. There was full reporting, and support was offered. For patients in seclusion, the report included a plan to reintroduce them back into the regular treatment environment.
Ontario Shores has used comprehensive reporting since 2014; it includes the average seclusion hours, individual patients and seclusion incidents. A separate report details mechanical restraint use and hours in seclusion.
Collaborating as a team brought leaders of various departments together working to a common goal. There has been a culture shift over the past five years. Management no longer operates in silos. The staff recognizes the balance between fostering an environment that promotes patient health and prioritizes the staff’s health and safety. Metrics dedicated to patient and staff safety have significantly improved.
Senior leadership created a real sense of ownership and accomplishment across the organization. Units are regularly recognized for their efforts (e.g. a 24-hour R&S free time triggers a notice to celebrate).