FOCUS PCDA:

FOCUS PDCA:

Improving Cardiovascular Screening in Mental

Health Community Centers

Background

Study: Improving Cardiovascular Disease Screening in a Community Mental Health Centers

Source: Perspectives in Psychiatric Care by Melissa Maki, DNP, RN, PMHNP-BC & Pamela Bjorklund, PhD, RN, CNS-BC, PMHNP-BC

The study stemmed from a research literature review, which highlighted the need to increase adherence to cardiovascular disease treatment as well as improve provider-patient and inter-agency communication. Researchers called for an investigation into the efficacy of education models and clinical tools. In the study, the MHC lacked a consistent, reliable mechanism for CVD screening: did not have prompts to assess tobacco use, family history of CVD, or to measure BMI. The MHC also did not properly communicate results to patients' PCPs.

Purpose

FOCUS-PDCA

(A) To evaluate current practices at the community MHC with respect to CVD screening and communication between mental health and primary care providers (PCPs).

(B) To develop clinical tools to improve existing processes of CVD screening

(C) To educate mental health providers: psychiatrists, advanced practice registered nurses (APRNs), registered nurses (RNs), and case managers - providers to clearly understand what they were checking, the disease itself to discuss treatment and lifestyle choices.

(D) To compare the results of pre and 6 months post educational intervention chart audits.

Goal

by: Sabrina Aguiar, Savanah Lochansingh & Albertina Qelaj

• FOCUS - PDCA model is a conceptual framework created by the Hospital Corporation of America. It is a problem solving method used for continuous quality improvement.
• It is a simple mechanism, designed to use current knowledge of a process to plan and test changes. It is process, not people focused.

To improve the health outcomes of patients by better monitoring and managing their cardiometabolic risk.

F - Find a process to improve

O - Organize a team that knows the process

C - Clarify current knowledge of the process

U - Understand causes of process variation

S - Select the process improvement

P - Plan the improvement

D - Do the improvement

C - Check data

A - Act to keep improving

Find a Process to Improve

The psychiatry clinic did not have a routine mechanism for thoroughly screening SMI patients at-risk for cardiovascular disease or communicating these results to patients' primary care physician.

Baseline Data & Information

Plan the Improvement

An important step, as the staff needed to have the necessary supplies and resources to provide the service to patients.

Organize a Team

Population: a nonprofit, Midwestern, community mental health center with a psychiatry department of 2,500 patients.

• Sample: the MHC center staff of two area assertive community treatment (ACT) teams and the MHC clinicians who worked with them (1 psychiatrist, 1 APRN, 2 RNs, 5 case managers and 2 support staff). The two ACT teams served those with serious mental illness (SMI).
• The first record review (pre-intervention) included 129 randomly selected clients from both ACT teams.

Do the Improvement

Researchers included a team of everyone that was involved in the process: the MHC center staff of two area assertive community treatment (ACT) teams and the MHC clinicians who worked with them (1 psychiatrist, 1 APRN, 2 RNs, 5 case managers and 2 support staff). The two ACT teams served those with serious mental illness (SMI).

At this step, the process improvement of basic education and a cardiovascular disease screening tool was implemented. The education portion involved being able to identify mental health center patients at risk for developing CVD and improving their overall health. The screening tool was a comprehensive CVD screening questionnaire and a reminder to order the appropriate lab tests as well as a form letter to communicate the results to the patient's primary care physician.

Select the Process Improvement

Clarify Current Knowledge

of the Process

An initial review was done to gather information on how cardiovascular disease screening was being conducted, documented, and then communicated.

Check the Data

The process improvement methods/tools picked by the researchers included:

• An educational workshop to help participants understand the project's purpose and give a basic understanding of CVD (definitions, types, etc) as well as identifiers of the CVD in mental health patients.
• The workshop also allowed stakeholders to understand the importance of CVD screening and discuss current screening processes & its problems.
• Implementation of new screening tool, which prompted providers to ask in-depth CVD screening questions (BP; weight; BMI; waist circumference; lipids including triglycerides, total cholesterol, low-density lipoprotein (LDL), HDL, fasting glucose, and hemoglobin A1c; tobacco use; family history), order the necessary lab tests and remind them to communicate the results appropriately via a form letter to the patient's primary care physician.

Understand the Causes

of Process Variation

Potential barriers to the process were identified, such as insurance limitations, non-adherence to treatment, and mental health symptoms.

Clinicians used the CVD screening tool for six months and after six months, the results were evaluated with a repeat audit of the same charts, however, the sample went from 129 patients to 117 patients.

• The post-intervention data was an evaluation of data six months after implementation of the educational workshop and the new CVD screening tool. Across the board, the tools were highly effective in improving CVD risk monitoring. Communication also increased from 19.2 (pre-intervention) to 32.3 (post-intervention).

CONCLUSION

Act to Keep Improving

In order to sustain to the changes made, the agency made a commitment to understand CVD and findings were shared with the entire organization. Furthermore, the new CVD screening process was implemented throughout the mental health center.

Using the FOCUS-PDCA model, the study identified a quality issue in the CVD screening of SMI adults at a community mental health center. An educational workshop, a comprehensive CVD screen and a form letter to primary care physicians were created and implemented in hopes of finding an increase in CVD screening to better identify and treat at-risk patients.

THANK YOU!

Limitations:

• While statistically significant, the process did not show that the CVD screening could be completed in full for all patients even with a psychiatric provider for every 50 patients.
• In larger institutions, it would be hard to implement such thorough screenings.

The results indicated a significant increase from pre-intervention to post-intervention. However, because of its limitations, the study ends with a call for continued quality improvement projects to improve mental health provider and PCP communication, increased access and adherence.