Improving Outcomes and Experience in Behavioral Health through Community Partnership

On the Road with Parkland Health & Hospital System – March 2019

by Michelle Garrison, CPXP and Stacy Palmer, CPXP

Our latest On the Road took us to Parkland Health & Hospital System in Dallas, Texas, one of the largest and busiest public hospital systems in the country, with more than one million outpatient visits annually and over 242,000 emergency department visits per year.

Parkland is a hospital rich in Dallas history. It was here that John F. Kennedy was brought to Trauma Room One. Walking the halls today, you can get a sense of this history and the homage and respect that it is given.

Our visit started with a tour of Parkland’s state-of-the-art hospital building, which opened in 2015. The 2.8 million-square-foot Parkland campus is nearly twice the size of the former hospital. One thing that stood out as we toured the space was the sense of openness and natural light usage.

Designed to put the “park” back in Parkland and with open spaces throughout, every aspect of the new hospital was thoughtfully planned to enhance the patient experience while ensuring safe, high quality care. The park theme is evident on the massive windows above the hospital’s main entry that when viewed from the outside form the images of trees etched in the glass. Inside, the windows are etched with the names of employees who were working at the hospital when they broke ground for the new facility as well as donors to the I Stand for Parkland campaign. A 923-foot sky bridge linking the new hospital with the old also showcases the etched trees.

Parkland’s leaders traveled across the country to visit other hospital construction projects taking what they learned from those experiences to give Parkland’s patients the best medical facilities. The lessons they learned are apparent in the intentionality of the design of the hospital. A hospitality layout with the on-stage and off-stage areas, similar to how Disney operates, was implemented to create a peaceful environment that promotes healing and increases patient satisfaction. The design helps keep some of the business of running a hospital separate from patients.

The hospital is divided in two distinct sections. The patient care areas are on-stage areas that feature quiet and uncluttered hallways where patients, visitors and staff can focus on the process of healing. With a pod style layout, featuring 10-12 private patient rooms, a supply room, a medication station and workrooms, staff do not need to leave their assigned patient area and can concentrate on taking care of patients at the bedside.

Each private patient room was designed to provide safe, quality care along with modern conveniences such shelves with electric outlets for charging electronic devices. Each patient room includes a large flat-screen television so patients and family members can watch educational videos tailored to their specific illness or injury as well as regular network programming. Care teams can also share information on white boards that surround the television The rooms are also large enough to offer space for guests to spend the night.

The off-stage area is located in the center, or core, of the inpatient units and is closed to the public. The off-stage areas include patient transport and staff-only elevators, work stations for medical personnel including doctors, nurses and other members of the care team, as well as other services such as medication rooms, nutrition services, clean and soiled linens and break rooms. The design also promotes privacy by providing clinical staff with a private space to discuss patient information, such as diagnosis and treatment options.

Vishal Bhalla, Vice President and Chief Experience Officer shared that it was only in recent months that staff had begun to use the public elevators. The elevator usage came with guidelines that included patients and visitors enter the elevators first before staff and when in elevators staff must be “present.” They are not to have their phones out and are encouraged to have conversations with patients and visitors, which creates a greater opportunity for connections.

The Dallas area experienced has experienced the closing of several hospitals and the loss of over 400 behavioral health beds which had an impact on the patient volumes that Parkland sees. Parkland was able to quickly implement strategies and tactics to assist in managing the influx they are now seeing. As Bhalla shared, “We are reacting to something out of our control. Our mission is to take care of our community.”

Connecting Patients to Services
Even before the community impact, behavioral health had been designated as top strategic priority for Parkland with plans to develop a comprehensive behavioral healthcare system that would bridge hospital services with outpatient services. Celeste Johnson, DNP, APRN, PMH CNS, Vice President of Nursing for Behavioral Health shared, “We were looking at the pieces and asking ‘how do we connect?’ Our goal is to break the cycle of patients coming to the hospital by connecting them to services in the community that support their needs.”

Some of the strategic goals of Parkland’s leaders include meeting the behavioral health needs of patients, decreasing utilization of emergency and inpatient services, decreasing utilization of correctional services, and enhancing collaborations with community partners.

As we met with staff throughout the day, we saw how Parkland is working to accomplish these goals and the teams that are enacting plans and strategies to connect not only patients but also the community to behavioral health services. “With the implementation of these services, we are able to connect the dots and function as an integrated delivery system,” shared Kenneth Rogers, MD, Chief of Behavioral Health Services.

Meeting the Behavioral Health Demands of Patients
The average stay for behavioral health patients is two weeks, and there is currently a waiting list for their 14 bed in-patient psychiatric unit that now has eight doubled rooms to bring capacity to 22 until construction of new beds is completed in late June. While doubling patient rooms is not ideal, it does provide an option to allow them to treat more patients. Parkland has plans in place to expand to 28 psychiatric beds in the coming months. In the meantime, to assist with meeting the current demands, Parkland has developed and expanded their programs, such as opening an Extended Observation Unit for Behavioral Health, where patients can participate in groups, individual counseling, milieu therapy, and medication management as their psychiatric emergency stabilizes and they are connected to community resources.

Integrated Care and Technology
Parkland leaders made a conscious decision to examine the use of integrated care with technology. One area where they are making strides is through their use of a Behavioral Alert program, developed as a communication tool to identify and develop interventions that target patient behaviors such as verbal threats, physical violence and property destruction. Following a report of patient aggression, the charge nurse will notify the Nursing Administration Officer on duty who will interview the patient and staff members to determine the need for an alert. The behavioral alert is revealed when the patient chart is opened along with a support plan to provide staff guidance on how to prevent or respond to the behavior.

A sample support plan template can include the following: behavior history, triggers for escalation, warning signs that the patient may escalate, ways staff can prevent those behavior from happening and interventions to help a patient regain control.

The overall goal of the program is to reduce incidents of patient aggression by helping to anticipate potential situations and understand potential triggers. The team is working to educate staff on when and how to initiate an alert and the value of alerting the next person of potential situations. As Naomi Cavett, Nursing Administrative Officer shared, “We are trying to change the culture. It’s a fine line of advocating for patients and not labeling them.”

Managing Behavioral Health Emergencies
With more patients needing treatment, increased pressure has been placed on the staff members working on non-mental health units, as they may not be trained to handle behavioral emergencies Parkland addressed this challenge with the creation of the Behavioral Emergency Response Team (B.E.R.T.), a group on call to assist with de-escalating patients experiencing behavioral emergencies.

This multi-disciplinary response team consists of a Psychiatric/Mental Health Advanced Practice Provider (physician assistant or nursing practitioner), psychiatric nurse, nursing administrative officer, and a L;fe Officer from Dallas County Hospital District Police Department. When a patient is escalating on a medical unit and BERT is activated, it takes the team approximately seven minutes to respond similarly as a code team would, the BERT, comes together to deal with the acute situation first. Once the situation has stabilized, the team will debrief with the nursing staff. In addition to helping to reduce the chance for traumatic experience for patients and providing more effective care and treatment, leaders believe usage of the team is reducing workplace violence.

Additionally, Rogers pointed out that the program provides an opportunity to educate staff on recognizing or de-escalating behavioral emergencies. “It can be very impactful for non-BERT staff observing the situation to see how others deal with crisis, for them to see how the experts do things.”

Decrease Utilization of Emergency and Inpatient Services
Parkland embraced the concept of providing primary care services in the community and in the late 1980s developed a network of neighborhood-based health centers located throughout Dallas County. These Community Oriented Primary Care (COPC) health centers are located in historically underserved areas of the county and have been replicated by health systems across the country. One of the services provided in these health centers is behavioral health.

By shifting patients to a primary care setting once they have stabilized, Parkland is able to provide patients with the services and/or resources they need while ensuring access to others.

Johnson acknowledged that the need is especially great for the indigent population, where fewer in-between services are typically available. “Patients need to be connected to community services so they can break the cycle of utilizing the Emergency Department for medication refills and non-emergency services that can be offered in an outpatient setting.”

Extended Observation Unit
With the opening of its Psychiatric Extended Observation Unit (P-EOU) last September, Parkland is able to provide psychiatric care in a safe and secure environment to individuals in crisis with the goal of reducing inpatient hospitalizations and connecting patients with community resources they need, including ACT/FACT teams, crisis residential services, housing/shelter, medications, medication management, and therapy services. The P-EOU, a partnership between Parkland and North Texas Behavioral Health Authority, is an extension of the hospital’s emergency department and offers open comfortable, walk around spaces with housing, food and medication available.

Embedding Behavioral Health Providers
Embedding behavioral health providers into primary care clinics also provides an opportunity to manage behavioral health conditions and provide services patients require.

The services in the clinic allow better coordination with primary care physicians and expands the services to treat addiction which has the added benefit of reducing hospitalizations. The care teams can also start to build a better rapport with patients. They can tailor treatment to individual patients and provide a level of security and comfort for patients with a continuous partnership. As Rebecca Corona, MD, Psychology Team Lead, shared regarding these services, “For patients, even once we finish treatment, I don’t disappear.”

Decrease Utilization of Correctional Services
Parkland provides the healthcare for those incarcerated in the Dallas County jail system, which includes an adult and adolescent population. A recent study found that roughly 17,000 people with mental illness are booked into the Dallas County jail annually, which makes it the largest provider of behavioral health service in the county. Parkland is focused on how they can impact the placement of patients in the criminal justice system. Started in 2018, Parkland’s Mental Health Peace Officer Program or L;FE Team strives to reduce the potential for violence during police contacts involving people suffering from mental illness. This goal is highlighted in the name of the team, with a semicolon in place of the “I”. The semicolon is a symbol of hope and love for those who are struggling with, or have struggled, with mental illness.

The mental health officers’ role is to recognize and deescalate interactions while continuing to strengthen the collaboration between police, mental health providers and the community they serve. The team currently includes six officers who participated in special training comprised of basic peace officer certification, crisis intervention training, a mental health peace officer course, customer service and effective communication skill training. As Chief Marlin Suell of the Dallas County Hospital District Police Department shared “There’s a special skill set for a L;FE officer – it takes the right person at the right place.”

These officers often spend hours with patients, sitting with them and building a rapport, developing a level of patience and talking to patients in their own language. They validate patients and help provide options. Often the officers will interact with patients through the system and get to know them. One example shared was how a patient in a difficult situation was relieved when an officer arrived because the officer knew his name and his story. As Capt. Anetta Linson shared, “We treat mental health patients as we would treat our loved ones. We truly care.”

Since the program’s launch, Parkland has seen a decrease in the number of patients placed in the criminal justice system who may have been exhibiting mental illness by getting them the help they need such as psychiatric treatment and medical assistance. Officer Roy Johnson summed it up as, “Our best force is to build relationships with communities to reduce bad outcomes.”

Enhance Collaborations with Community Partners
As the community faces growing behavioral health incidences, research shows that responding to these incidences requires more than a police response. This is where the Rapid Integrated Group Healthcare Team (RIGHT Care) pilot program comes in to play. The team, which is a pilot project currently only operating in South Central Dallas, includes mental health social workers, police and EMS working together to determine the proper treatment for the person in crisis when responding to 911 calls in South Central Dallas.

On the calls, the team evaluates the situation and determines the best course of action, whether it’s an immediate emergency response or a referral to a different provider. On site, the police office will screen for safety; the paramedic provides a medical evaluation; and the social worker conducts a psychosocial analysis.

The goal of the program is to make sure the city’s resources are allocated in a way that can help the most people and handle the crisis in the field when possible. Since the program inception, over 2,100 encounters have been conducted. This has the added benefits of establishing connection in the community as well as providing analytics for data sharing.

A Commitment to Patient Experience
As we wrapped up our visit, Parkland’s Patient Experience team shared stories of the impact their work has throughout the Parkland system, in behavioral health areas and beyond. The team consists of six advisors, each bringing a unique background and specialized training to the role, which has proven to be a key to their success. “For example, we have a team member with advanced SAMA (nonviolent de-escalation) training,” said Miranda Bond, MHR, CPXP, Patient Experience Director. “Not only has he brought that skill to the team, but he shares that knowledge with others so we’re all stronger.”

Another key to the team’s success is seen in their focus on providing services while focusing on long term success for patients. “Our job is to advocate for a resolution and to be a supportive resource by empowering patients. I will help facilitate with you but I also want to help you develop these skills for yourself,” Bond stated as she shared the story of helping a patient navigate the system to schedule follow-up appointments. Rather than handling things for the patient, she acted as a coach to teach the patient how to be his own advocate.

It is apparent Parkland is committed to providing services to impact their patients’ behavioral health needs as well as support their staff in providing these services. In one of our first conversations, Rogers noted that a warm hand off is key in the integrated health system model. By continuing to connect patients with services they need, both in the hospital and in the community, staff have the opportunity and time to build a rapport with patients so they can facilitate that transfer, and patients can feel support and trust in their next steps.