Rapid Cycle Improvement for Mental Health “Firsts” in Rockland County

“Mental Health First Aid,” BH first responders, Nyack Hospital coordinate care.

The words “rapid cycle improvement” have new meaning to those who participated in a groundbreaking project that has transformed crisis care in Rockland County.

Nyack Hospital is a suburban hospital with an emergency department (ED) inundated with behavioral health (BH) visits that are difficult to manage. In order to find a way to understand the system, Nyack Hospital, the Rockland County Department of Mental Health (DOMH), Rockland Paramedics, the Mental Health Association (MHA) of Rockland County, Refuah, and MHVC committed to a rapid cycle improvement (RCI) process. After six weeks of working with MHVC and Refuah in an RCI program in the Fall of 2016, the group is now embracing the process and developing creative solutions.

“In order to change a complicated system we need to understand what’s working and not,” said Kristin Woodlock, consultant to MHVC for this project  and former Acting Commissioner for NYSOMH. “Everyone should be able to identify a problem and then find creative solutions. The RCI program establishes an ‘esprit de corps,’ and a group sense of purpose to get to a common goal.”

The first step was to determine what kind of data to identify, and then to conduct a series of interviews with key organizations, such as the Behavioral Health Response Team (BHRT) run by Rockland Paramedics, the Rockland Psychiatric Center, and MHA of Rockland County. The first challenge the group addressed was the very high number of referrals to the Nyack ED from adult care homes, and children. While the numbers weren’t significant for children, they were a quality-of-care concern since their care took a lot of time in the ED. The next challenge was addressing data, and agreeing as a group on how to collect and use data to truly improve care.

In looking at adult home referrals to the ED, the group found that adult homes needed additional supports to deal with BH issues, and to give staff a better understanding of BH and the service system. MHVC provided “Mental Health First Aid” training by MHA of Rockland County, analogous to CPR for BH. “This is basic training for everyone, not just mental health professionals, to make staff more comfortable working with people in-house. It is an incredibly important effort nationwide to reduce stigma and increase awareness,“ said Stephanie Madison, LMSW, President & CEO, MHA of Rockland County. “This collaboration is a unifying effort, pulling together residential programs across Rockland County,” she continued. “We are creating a culture of healing in our community with a common language, common knowledge, and common skills, and reducing the stigma around dealing with those with mental health issues.” MHA also provides Mental Health First Aid for Youth, for adults who work with youth.

The County DOMH developed a crisis care plan template for adults in homes, which included procedures for working with the BHRT. Recognizing the need, Refuah contributed funds to support a second BHRT team, increasing capacity. Since the teams have down times (non-call), they initiated short 15-minute visits to the adult homes to for both “culture shift and building relationships with staff,” according to Tracie Florida, BHRT’s administrative coordinator and clinician. “We want to get to know our clients, so the first call is to us at BHRT versus the ED,” she said. If someone enters crisis, the BHRT can intervene. Rockland Paramedics is the one of the first paramedic units in the country to integrate a mobile mental health response team; a 25-person team providing 24-hour service also sets it apart. “We are getting calls from different people in the community, some new, some frequent utilizers, and a broad base of referral sources — including family, employers, schools, clergy — so we know we are accessible to everyone,” Florida said. “This is also a preventative service: You don’t have to wait until there’s a crisis or to have a diagnosis to access our services, someone could just be having a bad day.” The project began in the Fall of 2016; by December, there was a 70% reduction in calls to 911 from adult homes to Nyack Hospital, compared to the number of calls from June-December 2015.

Children in the ED are special cases and different innovations were needed. Some need a partial hospital program for two weeks to get back on track, but the only such program is at Westchester Community Medical Center, not nearby. Instead of starting a local program in Nyack, Refuah is paying for a ride-share service between Westchester and Nyack through community organization Konbit Neg Lakay, Inc., for kids who need the program. The group also developed an easier process for children who need an inpatient hospital by facilitating coordination between Nyack Hospital and Rockland Psychiatric Children’s Center.

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