Concurrent Session Topic: The Role of the Psychiatric-Mental Health - - PDF document

APNA 29th Annual Conference

Disney's Coronado Springs Resort - Lake Buena Vista, Florida October 28-31, 2015 Collaborating in an Evolving Health Care System: Opportunities to Advance Psychiatric-Mental Health Nursing

Concurrent Session

Topic: The Role of the Psychiatric-Mental Health Advanced Practice Nurse in the Behavioral Intervention Team (BIT) Model of Care Presenters: Jasper L. Tolarba, DNP, MSN, MA, RN, NEA-BC Joanne D. Iennaco, PhD, PMHNP-BC, PMHCNS-BC, APRN

APNA 29th Annual Conference Session 3042: October 30, 2015 Tolarba 1

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Yale School of Nursing Yale School of Nursing a e Sc oo o u s g

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015

Presented by

Jasper L. Tolarba, DNP, MSN, MA, RN, NEA-BC Joanne D. Iennaco, PhD, PMHNP-BC, PMHCNS-BC, APRN

The Role of the Psychiatric-Mental Health Advanced Practice Nurse in the Behavioral Intervention Team (BIT) Model of Care

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Yale School of Nursing Yale School of Nursing a e Sc oo o u s g

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015

Background

1 in every 4 adults

suffer from a diagnosable mental disorder

20% to 60%

Mild-to-Moderate Depression to more serious psychotic disorders like hallucinations or delusions

68%

adults with a mental disorder suffer from at least one general medical disorder

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Yale School of Nursing Yale School of Nursing a e Sc oo o u s g

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015

Psychiatric Models of Care

Psychiatric Consultation Model - psychiatrist evaluates the patient for any psychological or psychiatric condition after receiving a consult request from the primary medical service. Consultation-Liaison (CL) Model - psychiatric service with more active collaboration with medical teams to provide care to patients with psychiatric morbidity within the general medical setting. Integrated Model of Care (IMC)- care delivered by general medical physicians working with psychiatrists and other allied health professionals to provide complementary services, patient education, and management in order to improve mental health outcomes

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APNA 29th Annual Conference Session 3042: October 30, 2015 Tolarba 2

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Yale School of Nursing Yale School of Nursing a e Sc oo o u s g

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015

Behavior Intervention Team ( BIT ) at YNHH

Evidence-based Practice in Psychological Medicine Service - Using an ABA (basic withdrawal) design with a 33-day intervention period and 10 similar control periods, the BIT model

• f care demonstrated significant

positiveresults.

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Yale School of Nursing Yale School of Nursing

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015 Positive Impact of BIT Decreased patient LOS by 1.2 days

Overall financial gain for the hospital Quicker response to patient sitter evaluation

Increased staff satisfaction Decreased payer denied days

Outcome of Project Implementation

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Yale School of Nursing Yale School of Nursing a e Sc oo o u s g

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015

Objectives

To describe the BIT model of care and focus on the role of the Psychiatric-Mental Health Advanced Practice Nurse (PMHAPN). More specifically to: (1.) Describe the overall context and structure of the BIT and the roles and responsibilities of members, (2.) Describe the PMHAPN’s clinical and operational responsibilities, (3.) Describe the collaborative relationships among stakeholders involved in the care of the client; and (4.) Validate the overall BIT model of care and the role of the PMHAPN with a group process.

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APNA 29th Annual Conference Session 3042: October 30, 2015 Tolarba 3

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Yale School of Nursing Yale School of Nursing a e Sc oo o u s g

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015

Methods

• 1. Writing the initial description of the BIT structure as well as the roles and

responsibilities of each member

• 2. Describing the concept of the collaborative and integrated nature of the BIT

model of care

• 3. Identifying the multifocal roles of the PMHAPNs as they function within the

BIT model of care.

• 4. Validation via a group process involving all members of the BIT at YNHH.
• 5. Rewriting the paper incorporating the suggestions and feedback by the BIT

team members

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Yale School of Nursing Yale School of Nursing a e Sc oo o u s g

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015

Conceptual Framework

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Yale School of Nursing Yale School of Nursing a e Sc oo o u s g

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015

Results

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APNA 29th Annual Conference Session 3042: October 30, 2015 Tolarba 4

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Yale School of Nursing Yale School of Nursing a e Sc oo o u s g

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015

BIT Structure and Roles

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Yale School of Nursing Yale School of Nursing a e Sc oo o u s g

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015

BIT Daily Clinical Process

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Yale School of Nursing Yale School of Nursing a e Sc oo o u s g

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015

Integrated and Multidisciplinary Care

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APNA 29th Annual Conference Session 3042: October 30, 2015 Tolarba 5

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Yale School of Nursing Yale School of Nursing a e Sc oo o u s g

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015

Multifocal Role of BIT PMHAPN

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Yale School of Nursing Yale School of Nursing a e Sc oo o u s g

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015

Program Success Indicators

Patient Outcomes Peer Outcomes Organizational Outcomes

decreased patient LOS staff satisfaction with the BIT increased patient volume medication compliance increased knowledge and skill to care for this pt population decreased denial days from payers effective symptom management continuing education provided decreased patient sitter utilization participation in plan of care decreased staff injuries related to behavior situations early safety risk identification

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Yale School of Nursing Yale School of Nursing a e Sc oo o u s g

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015

Identified Future Directions of BIT

• 1. Establishing an outpatient clinic associated with BIT where patients

can be seen after discharge as they transition to longer-term care (i.e. in the 6-week to 3-month gap before seeing a prescriber at an

• utpatient clinic).
• 2. BIT clinicians would continue to follow their patients in this BIT-

established outpatient clinic due to familiarity of patient case and to establish continuity of care.

• 3. Expansion of BIT program in other Service Lines as well as other

institutions throughout the country

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APNA 29th Annual Conference Session 3042: October 30, 2015 Tolarba 6

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Yale School of Nursing Yale School of Nursing a e Sc oo o u s g

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015

Conclusions

• 1. The proactive approach in providing psychiatric services to patients in

a general medical inpatient setting has been proven effective, which has fueled replication of the BIT program in other hospitals in the country.

• 2. The active involvement of BIT members in the overall care of the

patient, coupled with a successful collaborative relationship between BIT and various disciplines resulted in positive clinical and operational

• utcomes.
• 3. The multifocal responsibilities of the PMHAPN as a clinician, educator,

coordinator, and researcher have made this role an integral part of BIT

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Yale School of Nursing Yale School of Nursing a e Sc oo o u s g

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015

Thank You!

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Yale School of Nursing Yale School of Nursing a e Sc oo o u s g

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015

Questions?

Jasper L. Tolarba, DNP, MSN, MA, RN, CCRN, NEA-BC Director of Nursing, Tufts Medical Center 800 Washington Street Boston, MA 02111 (617) 636-2560 jtolarba@tuftsmedicalcenter.org Joanne D. Iennaco, PhD, PMHNP-BC, PMHCNS-BC, APRN Associate Professor of Nursing Yale University School of Nursing 400 West Campus Drive Orange, CT 06477 (203) 737-2595 joanne.iennaco@yale.edu

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APNA 29th Annual Conference Session 3042: October 30, 2015 Tolarba 7

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Yale School of Nursing Yale School of Nursing a e Sc oo o u s g

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015

Acknowledgment

William Sledge, MD - Yale Psychiatric Hospital Medical Director Hochang (Ben) Lee, MD - YNHH Psychological Medicine Service Medical Director Paul Desan, MD, PhD - YNHH Consultation-Liaison Service Medical Director Katy Perticone, BIT APRN Beth Heaney, BIT APRN Pat Cunningham, BIT CNS Nancy Tommasini, BIT CNS Alonzo Watts, BIT LCSW Anne Marie Granata, BIT LCSW Mark Oldham, MD - BIT Attending Psychiatrist Pamela Petersen-Crair, MD - BIT Attending Psychiatrist Griserl Nieves - BIT Coordinator Kris Diana- CL Coordinator

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Yale School of Nursing Yale School of Nursing a e Sc oo o u s g

Jasper Tolarba, DNP, RN and Joanne Iennaco, PhD, RN

APNA 29th Annual Conference, October 28-31, 2015

References

Desan, P., Zimbrean, P., Weinstein, A., Bozzo, J., Sledge, W. (2011). Proactive psychiatric consultation services reduce length of stay for admissions to an inpatient medical team, Psychosomatics, The Academy of Psychosomatic Medicine, Elsevier, Inc. 52:6 Mohammed, A., Said, J., Wakil, M., Rabbebe, I., Sheikh, T., Agunbiade, S. (2014). Unrecognized psychiatric disorders among adult patients admitted into a general hospital in Maiduguri, Northeastern Nigeria , Pan African Medical Journal, Volume 19, 24 Polikandrioti, M., Christou,A., Morou,Z., Kotronoulas,G., Evagelou, H., Kyritsi, H. (2010). Evaluation of depression in patients with heart failure, Health Science Journal, Volume 4, Issue 1. Rothenhäusler, H. (2006). Mental disorders in general hospital patients, PsychiatriaDanubina, 18(3-4):183-92 Royal College of Psychiatrists (2005). Who cares wins: Improving the outcome for older people admitted to the general hospital: Guidelines for the development of Liaison Mental Health Services for older people. London, Royal College of Psychiatrists. Kissane, D., Grabsch, B., Love, A., Clarke, D., Bloch, S., and Smith, G., (2004). Psychiatric disorder in women with early stage and advanced breast cancer: a comparative analysis, Australia New Zealand Journal of Psychiatry, 38(5):320-6. Freedland, K., Rich,M., Skala,J., Carney, R., Davila-Roman, V., Jaffe, A. (2003). Prevalence of depression in hospitalized patients with congestive heart failure, Psychosomatic Medicine, 65, pp. 119–128 Diefenbacher, A. and Strain J. (2002). Consultation-liaison psychiatry: stability and change over a 10-year period, General Hospital Psychiatry, 24: 249- 56 Katon, W, Von Korff M, Lin, E.(1995). Collaborative management to achieve treatment guidelines Impact on depression in primary care, Journal of American Medical Association, 273:1026–1031

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