Posts from the ‘timely access’ category

Extending Access to Psychiatric Care for Pregnant, Postpartum Patients

While pregnancy, childbirth and motherhood are joyful times for many women, for others these experiences can be emotionally challenging, isolating or even traumatic. An estimated one in seven women experiences depression during pregnancy or in the first year after giving birth – making depression during this time nearly twice as common as gestational diabetes. 

But unless a mother or mother-to-be already has an established relationship with a behavioral health provider, she faces multiple barriers in terms of accessing specialized care to prevent, identify and manage mental health and substance use concerns.

“Psychiatrists who are trained in and comfortable with treating pregnant and postpartum patients are an extremely limited resource. There are simply not enough,” said Leena Mittal, MD, director of the Division of Women’s Mental Health in the Department of Psychiatry. “Meanwhile, in low-resource areas like Central and Western Massachusetts, the wait time to see any psychiatrist – let alone a perinatal psychiatrist – could be three or four months. In Southeastern Mass., it could take more than six months.”

That usually leaves primary care providers and obstetricians on the front line, but they don’t typically receive the specialized training necessary to feel confident treating these patients either, Mittal said. 

Helping to bridge that gap is the Massachusetts Children Psychiatry Access Program (MCPAP) for Moms, which provides free, real-time perinatal psychiatric consultations and referrals for obstetric, pediatric, primary care and psychiatric providers across Massachusetts. The Brigham serves as the Boston hub for the program, which is based out of the University of Massachusetts Medical School in Worcester. 

Supporting Patients and Providers

From fluctuating hormones to sleep deprivation to a traumatic childbirth, there are a number of circumstances that can make pregnancy and motherhood a difficult time for patients. 

Leena Mittal

Launched four years ago, MCPAP for Moms maintains a consultation, resource and referral phone line that providers can call to receive guidance on diagnosing, treating and prescribing medications for pregnant and postpartum women with mental health or substance use concerns. For complex cases, perinatal psychiatrists in the program conduct in-person consults with patients. The service can also help frontline providers identify other relevant community resources or help facilitate referrals to group and individual therapy or other services.

For example, if an obstetrician suspects that a patient who’s come in for a prenatal care visit is showing signs of depression, the provider could call MCPAP for Moms and ask for input on a possible diagnosis and treatment plan, explained Mittal, one of two Brigham psychiatrists who provide consults through the program.

“There’s this misconception that pregnancy is a time when women are always ‘glowing’ and happy, but it can be a complicated time,” said Mittal, who also serves as associate medical director of MCPAP for Moms. “In addition, women – and sometimes their providers – assume they have to stop all medications, including antidepressants, during pregnancy. But that’s not the case. We give providers evidence-based guidelines, and they can ask questions as needed.”

Nicole Smith, MD, MPH, of the Department of Obstetrics and Gynecology, has used MCPAP for Moms’ services in her practice and recommended it to colleagues as a novel, vital resource for providers. 

“A lot of programs tend to focus on trying to increase the number of and access to therapists and psychiatrists, which is wonderful and very necessary, but that may not meet our patients’ needs,” said Smith, an unpaid obstetric consultant for the program. “Patients can receive great, timely care from their primary care doctor or obstetrician, who may just need confirmation that a treatment is appropriate or a best practice.” 

MCPAP for Moms supplements the Brigham’s robust in-house psychiatric resources, she added. For example, the program makes it easy to help patients who live outside Boston find support services closer to home. “Many patients don’t want to drive to the city with a newborn, and that can be an obstacle to accessing treatment,” she said.

Looking ahead, MCPAP for Moms is expanding its services to support providers caring for perinatal patients with substance use disorders, an effort that will be based out of the Brigham and led by Mittal. 

“Massachusetts is the first state in the country with a program like MCPAP for Moms, and getting to be part of something so innovative has been very exciting,” she said. “We’re moving the needle in the way that perinatal mental health is treated, and I’m thrilled to be part of that.” 

Learn more at mcpapformoms.org or contact MCPAP for Moms at 855-MOM-MCPAP (855-666-6272). Providers interested in training opportunities around perinatal mental health and substance use are also encouraged to contact the program.

Brigham Health’s Strategy in Action: Timely Access
Learn more about our strategic priorities at BWHPikeNotes.org.

Innovative Pilot Improves ED Access, Reduces Walkouts

Emergency Department staff gather to celebrate a year of a sustained reduction in walkout rates.

A cornerstone of any emergency department (ED) is to see the sickest patients first – a practice that has saved countless lives. But it has the unintended side effect of leaving patients with less-acute symptoms waiting to be seen by a physician when the department is at capacity.

“Previously, some patients waited several hours to be seen for an issue that takes five or 10 minutes to address, such as a medication refill or wound evaluation that doesn’t need an intervention,” said Christopher Baugh, MD, MBA, medical director of the ED in the Department of Emergency Medicine.

When the ED is at capacity, some patients leave after being seen by a triage nurse, but before being seen by a physician. When a “walkout” occurs – often due to long wait times – it not only leads to a poor patient experience, but it is also a safety concern, as nearly 30 percent of patients who receive care in the Brigham’s ED are sick enough to be admitted.

Over the past year, a multidisciplinary team has piloted a care delivery model that reduced door-to-physician time and sustained lower ED walkout rates. The intervention centered on turning two sections of the ED known as surge areas – nonclinical spaces that were temporarily used to see patients during high-volume periods – into regularly staffed areas where patients could be seen by a physician within about 20 minutes of arrival. In addition, ED Radiology partnered with the team to flag certain imaging orders to expedite a patient’s evaluation.

Now operational and staffed every weekday during peak times, the surge spaces consist of the “front end” – a curtained-off section of the waiting room – and one hallway inside the ED, where eight stretchers are separated by opaque dividers.

Faster Access to Care

Prior to the intervention, a patient who checked into the ED would be seen by a triage nurse and have their vital signs checked. If the patient wasn’t identified as critically ill and there was not an available treatment space, further care – such as lab testing, imaging or pain medication – was delayed until a room was available.

Lower-acuity patients, such as those who come in with a sore throat or sprained ankle, are now often able to be seen in the front end shortly after arrival. When in use, the area is staffed with a physician, nurse, nursing assistant and medical scribe. The area can accommodate four to five patients at a time. Most patients seen in the front end can be treated and safely discharged from there.

“It’s definitely a different way of doing things, and it’s much quicker,” said Sue Botsch, RN, an ED nurse who staffs the front end. “You’re not waiting for things to happen because the team is right here. I like that it’s a real-time application of care, and patients appreciate going home in an hour.”

Staff Support Drives Success

Prior to the intervention, ED walkout rates ranged from about 2.5 to 4 percent, with some individual days reaching as high as 8 or 9 percent. Since implementing the new model in December 2016, the walkout rate has consistently remained under 2 percent since January 2017, with one month as low as 0.7 percent.

“As soon as we opened this surge capacity as a regular practice every weekday, we saw the walkout rate drop dramatically and immediately,” said Jonny McCabe, BSN, RN, operations director in Emergency Medicine.

Pivotal to the initiative’s success has been a cultural change among ED staff, said Janet Gorman, MM, BSN, RN, executive director of the ED.

“We owe it to our community to be available for them, and if there’s no access, we’re doing them a disservice,” Gorman said. “I’m so proud of our staff, who truly took ownership of this work to improve how we care for our patients.”

Anna Meyer, DNP, RN, interim ED nursing director, said the pilot’s success reflects the team’s commitment to multidisciplinary collaboration.

“We definitely stepped outside our comfort zones, but everyone’s continued hard work has paid off for our patients,” Meyer said. “The sustained success shows how well we work together.”

Looking Ahead

Still, the team sees room for improvement. In monthly Press Ganey surveys, some ED patients report concerns regarding privacy and comfort – feedback the team takes to heart, Baugh noted.

“There is certainly a tradeoff,” he said. “Hallway and surge-area care are short-term interventions that improve patient safety by lowering our waiting room census and walkout rate. We track these metrics and share them with hospital leadership because we need everyone to understand how hospital crowding affects ED care.”

Although the upcoming ED expansion will add 30 beds and alleviate some of the current challenges, Baugh underscored the importance of taking what the team has learned from the pilot and incorporating those efficiencies into the new design.

“We have to change the way we engage with our patients – not just add more treatment rooms,” he said. “We think we can borrow from this process and continue to refine it to get even better use out of our new space.”

Brigham Health’s Strategy in Action: Timely Access
Learn more about our strategic priorities at BWHPikeNotes.org.

DF/BWCC Opens New England’s First Adult Cancer Diagnostic Service

From left: Cancer Diagnostic Service team members Luke Arney and Louise Schneider

Sometimes, a routine medical examination leads to more questions than answers. But for patients with suspicious and complex symptoms that point to cancer, not receiving concrete answers right away about their diagnosis can be especially scary.

Take, for instance, a patient who met with her Partners HealthCare-affiliated primary care physician (PCP) for a routine lung cancer screening. While a chest CT scan didn’t show signs of lung cancer, it did reveal a bone lesion and pathologic rib fracture, a form of rib injury caused by disease rather than blunt trauma. Additional tests suggested cancer, but her doctor wasn’t sure.

Such a patient poses an unusual challenge. A referral to an appropriate oncologist is difficult because a cancer diagnosis has not been made, but the next steps in the diagnostic workup aren’t always clear either for PCPs. Yet the prospect of a cancer diagnosis also creates stress, so everyone wants answers as soon as possible.

The Cancer Diagnostic Service (CDS) at Dana-Farber/Brigham and Women’s Cancer Center (DF/BWCC) aims to alleviate that uncertainty and make the determination of a cancer diagnosis faster and simpler for patients and their providers. Initially piloted as a virtual clinic to help Partners-affiliated PCPs streamline and expedite a diagnosis for patients with suspected cancer, the CDS recently graduated from its pilot phase and began seeing patients in its new physical space on the main campus.

While the service’s biggest users at the moment are PCPs within Partners, including those at the Brigham, it is expected to grow into a regional resource for referring physicians at other health care organizations as well.

“When there is a strong suspicion of cancer without a definitive diagnosis, it can be difficult for patients and physicians,” said Lindsay Carter, MD, MBA, medical director of the Cancer Diagnostic Service. “As doctors order additional diagnostics test for their patients or seek input on the appropriate next steps, there can be significant delays and unnecessary tests. We created the Cancer Diagnostic Service to streamline the process to help doctors reach a timely diagnosis so that treatment can begin without delays.”

The patient with suspicious findings on her lung CT was referred to the CDS, where she was diagnosed with adenocarcinoma – a form of cancer – following a CT-guided biopsy. She was then seamlessly transferred to a thoracic oncologist at Dana-Farber Cancer Institute (DFCI) to begin treatment.

A More Seamless Approach

During the center’s six-month pilot, which began in October 2016, providers used Epic’s E-consult function to consult virtually with CDS staff. Of the 82 cases evaluated by the clinic’s staff – an internist, physician assistant and consulting BWH and DFCI oncology specialists – 70 percent of patients were recommended for and received a full diagnostic work-up. Among that group, nearly two-thirds were ultimately diagnosed with cancer and referred to oncologists or surgeons.

The pilot generated an overwhelmingly positive response from PCPs. “It’s scary when your patient has cancer, and it was really nice to have someone guide you as you make diagnostic decisions,” wrote one physician in a feedback survey. Others praised the rapid response and seamless process in reaching a diagnosis.

With funding from the Brigham Care Redesign Incubator Startup Program (B-CRISP) and DFCI, the CDS opened its physical space on Oct. 20 in the Brigham Medical Specialties Suite at 45 Francis St. The team sees patients on Wednesday mornings and Friday afternoons. Patients are scheduled for an appointment within five business days of the referral.

“After a referral, the CDS takes ownership of each patient’s case and coordinates the diagnostic work-up. We communicate detailed results and a suggested treatment plan to both patients and referring providers,” said Ryan Leib, MBA, administrator for the CDS and director of Ambulatory Practice Management at DFCI. “Now that we have an established physical location, we are reaching out to the referring physician community to inform them about this unique service.”

To refer a patient the Cancer Diagnostic Service, call 857-307-5775. Partners HealthCare physicians may also submit an Epic order to Ambulatory Referral to DF/BWCC Cancer Diagnostic Service.  

Brigham Health’s Strategy in Action: Timely Access
Learn more about our strategic priorities at BWHPikeNotes.org.

Brigham Health Access Center Serves as Central Hub for Transfers

Assistant Nurse Director Laurie Rotondo takes notes during a call in the Brigham Health Access Center.

The new Brigham Health Access Center, launched at midnight on April 1, centrally manages referrals to the Brigham’s Emergency Department (ED) and inpatient units. Its goal is to facilitate timely, high-quality and safe patient transfers in just one phone call.

A team of nurses and transfer access coordinators triage transfer requests from area hospitals. The center’s staff ensures patients are sent to the most appropriate location for care, whether that is the ED or an inpatient unit at BWH or BWFH.

“Our goal is to provide a seamless process for our referring facilities and physicians to get easy access to Brigham Health. A centralized approach really simplifies the process for our care partners in the community,” said Sheila Harris, executive director of the Brigham Health Access Center and Patient Access Services.

The Access Center was formed to make the transfer process more efficient, in light of growing transfer volume at BWH in recent years.

Previously, personnel in the ED and Admitting operated independently from each other. For example, ED flow managers handled requests for transfers, but that model posed challenges. Primarily, flow managers had limited insight into bed availability across the institution, Harris explained.

“Based in Admitting, the Access Center team uses a centralized approach to review real-time information about inpatient bed availability,” she said.

In addition, handling transfer requests was just one of many duties for the flow manager on a given shift. If he or she was on another call or had stepped away, the delay might prompt the outside hospital to hang up and try another facility.

“By having a knowledgeable, experienced and caring staff dedicated solely to transfers 24 hours a day, seven days a week, we are enabling more patients to access the high-quality care that Brigham Health is known for,” said Eric Goralnick, MD, MS, medical director of the Brigham Health Access Center and Emergency Preparedness.

All calls to the Access Center are recorded, and surveys are sent to referring providers to gather feedback, with the aim of identifying ways the center can continually improve the transfer experience. In the future, the team hopes to incorporate telemedicine as another tool for receiving transfers.

Ali Salim, MD, chief of the Division of Trauma, Burns and Critical Care, said he looks forward working with the center.

“This is a phenomenal opportunity to ensure that patients are transferred to us efficiently and smoothly,” Salim said. “It will undoubtedly benefit our patients and our community care partners.”

Brigham Health’s Strategy in Action: Timely Access
Learn more about our strategic priorities at BWHPikeNotes.org.

Q&A: Introducing Brigham Health

bh_bwh_pms_293Brigham Health was unveiled earlier this week as the new name for the parent organization that includes Brigham and Women’s Hospital, Brigham and Women’s Faulkner Hospital and the Brigham and Women’s Physicians Organization. All three entities will retain their individual names and identities. Brigham Health replaces Brigham and Women’s Health Care (BWHC). 

Brigham Health President Betsy Nabel, MD, discusses with BWH Bulletin what this change means for us. 

Why did we change from BWHC to Brigham Health?

Nabel: Those who know the Brigham think of it as a top-tier New England hospital – a place to go for care when needed, especially complex procedures. But according to market research, many outside of New England assume we are solely a women’s hospital. And while we are certainly a leader in women’s health care, we want to be sure it’s clear that our excellence and expertise extend to so many other areas. Brigham Health reinforces that we are not just one point on a map, or even a single point of discovery.

The new name eliminates some of the confusion we have found among those outside of New England. Talking about the services of BWH, BWFH and the BWPO as simply Brigham Health will enable us to more effectively reach people who are seeking health information, referrals and care.

How does this change fit into our strategy?

Nabel: This change is a vital component of our institutional strategy. For example, one of our strategic priorities is to improve health. In addition to providing highly specialized care in the hospital and ambulatory settings, we also must engage people around the world as we promote health and wellness and concentrate on preventing disease in populations.

Another example is twofold. By building national and international lines of business, we reinforce our financial strength and advance our work in business development – two areas essential to guaranteeing we continue delivering on our mission.

Why was the name Brigham Health selected?

Nabel: Brigham Health reflects our role as a leader in maintaining and restoring health around the world, encompassing all that we do in delivering care, advancing scientific discovery and educating the next generation of health care professionals. It broadly defines everything we do today and provides a new platform for amplifying our commitment to what everybody desires: health.

For more Brigham Health information and resources – including an FAQ, downloadable logos and presentation templates – visit BWHPikeNotes.org

StrategyIcon_WordpressBrigham Health’s Strategy in Action
Learn more about our strategic priorities at BWHPikeNotes.org.

Convenience and Compassion: Telehealth Delivers Both to BWH Patients

Ash Nadkarni demonstrates a virtual visit in her office at 850 Boylston St.

Ash Nadkarni demonstrates a virtual visit in her office at 850 Boylston St.

When Ash Nadkarni, MD, of the Department of Psychiatry, was offered the opportunity to start seeing some patients through virtual visits, she jumped at the chance.

For patients with medically complex conditions, getting to a behavioral health appointment can be physically challenging. As one part of her practice, Nadkarni provides psychiatric care for patients with inflammatory bowel disease through BWH’s Crohn’s and Colitis Center. The ability to follow up with select patients in this group through the use of technology such as video conferencing on a computer or mobile device wasn’t just a matter of convenience – it was also about having compassion for patients’ physical limitations.

“A lot of times, these patients are medically ill, and appointments in person can be uncomfortable for them,” said Nadkarni, one of about 200 clinicians participating in the Brigham’s telehealth initiative. “Virtual visits really give them improved access to care.”

The telehealth program at BWH, launched in early 2015, uses web-based and video technologies to connect patients and providers in virtual visits. Now in the process of wrapping up its pilot stage, the initiative has facilitated about 600 virtual visits among outpatient clinicians in various specialties. Today, BWH clinicians collectively see approximately 10 to 20 patients per week through virtual care. That is expected to climb to 100 per week over the next year as the program expands.

The program has several goals, according to Adam Licurse, MD, MHS, Telehealth medical director.

Telehealth provides more timely access for appointments, as providers don’t need exam room space and can fill a last-minute cancellation slot with a virtual visit on short notice. And because there is no need to drive, park or sit in a waiting room to see a provider, patients may find virtual visits to be more convenient and therefore are more likely to keep their appointment. The expected result of all this: improved patient outcomes and reduced costs of care.

“Virtual care is becoming a vital clinical service, and the initial successes of our pilots have empowered us to expand these efforts across the Brigham in the coming years,” Licurse said. “By offering several telehealth tools across the clinical spectrum, we hope patients can access care in whatever way works best for them – whether they’re at home, work or a clinical setting. Combined with the right level of in-person care, virtual care can be a better option for many patients, and we look forward to delivering this type of care to more patients locally, nationally and internationally, and meeting the needs of new populations as our programs grow.”

For the Right Patients, at the Right Time

The program initially engaged departments whose providers saw patients with conditions that required frequent follow-up visits and infrequent physical exams, and who lived in Massachusetts but had difficulty coming to their provider’s office, Licurse said. Candidates for the pilot were further narrowed down to patients with inflammatory bowel disease, diabetes during pregnancy, mood disorders, hypertension, ischemic heart disease, prostate disease and airway disorders.

BWH’s telehealth initiative has since expanded to include e-visits to provide urgent care for patients with common, acute symptoms. Patients can submit text-based inquiries through a patient portal, and if their symptoms match the covered conditions, a clinician will typically respond within a day.

“For certain common and irritating symptoms, seeing one’s provider in the office is often less important than obtaining a speedy and reliable answer,” Licurse said. “From early experiences, we know that a 15-minute office visit for urinary symptoms or a cough can be done in less than five minutes through this program.”

For Nadkarni, virtual visits are like other tools available to clinicians—such as the Patient Gateway online portal—to help provide greater access for patients. Since initially piloting the technology with patients referred from the Crohn’s and Colitis Center, she has expanded her use of virtual visits to other patients in her practice.

“One of the things I realized was that virtual visits are useful not exclusively for some patients, but for all patients at certain times,” she said. “For some patients, it takes so much time to come in—some have to take a half-day off of work, which can be a huge inconvenience. It can also be challenging for patients with young children to find child care so they can come to an appointment.”

Although the conversations a patient has with a psychiatrist can be sensitive and sometimes difficult, the trust and intimacy such discussions require isn’t diminished when they take place through a webcam, Nadkarni says.

“Patients tell me they feel heard because I’m looking directly at the screen for the whole appointment,” she said. “There’s no question that when the doctor is beside you and treating you there, that’s a human element that cannot be replicated by virtual visits. But when we use virtual visits appropriately, for the right patients at the right time, that experience isn’t lost.”

StrategyIcon_WordpressBWHC’s Strategy in Action: Timely Access
Learn more about our strategic priorities at BWHPikeNotes.org.