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\begin{document}

\title{Actionable Patient Safety Solutions \#13B: Collaborative Care Planning}



\author[1]{Monica McAlduff}%
\author[1]{Janice Fyfe}%
\author[2]{Jacob Lopez}%
\author[2]{Ariana Longley}%
\author[2]{Anita Everett}%
\author[3]{Carol Hessler}%
\author[4]{Dorris Fuller}%
\author[2]{Elaine Shamir}%
\author[5]{Elizabeth Holmes-Walker}%
\author[6]{Heather Huszti}%
\author[7]{Isabelle Desjardins}%
\author[8]{Leila Entezam}%
\author[9]{Maggie Merritt}%
\author[10]{Michael I. Mestek}%
\author[11]{paul}%
\author[12]{Robert Roca}%
\author[13]{Ron Honberg}%
\author[14]{Sheree Lowe}%
\author[2]{Steven J. Barker}%
\author[15]{Vikas Duvvuri}%
\author[1]{Monica McAlduff}%
\author[2]{Jane Sun}%
\affil[1]{Vancouver Mental Health and Substance Use}%
\affil[2]{Patient Safety Movement Foundation}%
\affil[3]{Inova Health System}%
\affil[4]{Treatment Advocacy Center}%
\affil[5]{University of Pittsburg Medical Center}%
\affil[6]{Children's Hospital of Orange County}%
\affil[7]{Wiser Systems}%
\affil[8]{Patient Valet}%
\affil[9]{Steinberg Institute}%
\affil[10]{Medtronic}%
\affil[11]{Affiliation not available}%
\affil[12]{Sheppard Pratt Health System}%
\affil[13]{National Alliance on Mental Health}%
\affil[14]{California Hospital Association}%
\affil[15]{Universal Health Services, Inc.}%


\vspace{-1em}



  \date{}


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\par\null

\section*{Executive Summary Checklist}

{\label{994700}}

Clinicians and Physicians in acute mental health units rely on the
environment, medications and care planning to provide treatment to
patients and ensure patient safety. Active care planning during acute
mental health treatment that is inclusive of the patient and other
supports can have a positive effect on reducing harm to patients, staff,
and visitors, by increasing resources for amelioration of strong
negative emotions. In this project, active and collaborative care
planning is operationalized as the combined use of Comfort Plans and
Comfort Kits for assessment and intervention, respectively. This will:

\begin{enumerate}
\tightlist
\item
  Provide low barrier ways for staff and patients to collaborate on care
  planning.
\item
  Promote patients to take more of an active role in identification and
  management of symptoms.
\item
  Increase patient safety by increasing awareness of and interventions
  for strong negative emotional states which may precede harm of self or
  others.
\item
  Be evaluated with metrics such as Client Satisfaction Surveys, patient
  lengths of stay, patient readmission rates, Code White frequency, and
  seclusion room use.
\end{enumerate}

\section*{The Performance Gap}

{\label{861452}}

Patient safety events in psychiatry are a serious concern; one thousand
five hundred suicides take place on inpatient psychiatry units in the
United States each year, over 70\% by hanging (Mills et al, 2013).
Suicide is not the only metric for patient safety in psychiatry, which
has other unique patient safety issues, such as violence and aggression;
suicide and self-harm; seclusion and restraint; and absconding and
missing patients. Seclusion rates in an acute inpatient psychiatry unit
can reach as high as 31\%, with the most common indicator of seclusion
was risk to others (74\%) followed by risk to self (61\%) and risk of
absconding (55\%) (Tunde-Ayinmode et al., 2004). Up to 47\% of mental
health care providers have experienced violence at work (Nolan, 1999).
As such, there is an urgent need to reduce and mitigate unsafe acts
within the mental health care system.

Patients who are in acute psychiatric distress are at risk to harm
themselves or others.~ Collaborative care planning is a tool used to
help patients recognize when they are reaching levels of acute
psychiatric distress. This self recognition translates into preventing
patients from reaching a point of crisis where they are at risk to harm
themselves or others.~Acute inpatient settings often do a good job of
utilizing the environment and medications to promote patient recovery.
Patients are admitted to a relatively safe, calm environment removed
from the complexities of life that may have triggered the acute
psychiatric crisis, and patients receive medication trials under close
medical supervision to determine the best pharmacological treatment
plan. However, a third arm of treatment, collaborative care planning, is
often underutilized (Anthony, P. \& Crawford, P., 2000).~

Collaborative care planning refers to the combined efforts of staff and
patients working together to set and achieve health goals, and involves
greater patient involvement in the planning, delivery and evaluation of
care. Ideally, it leads to better treatment by focusing on improving and
maintaining health rather than just dealing with problems as they arise
(Victoria State Government, 2012)). Lack of collaborative care planning
often manifests as: patients being unaware of their treatment plan;
patients feeling helpless; weak therapeutic relationships between
patients and staff. This, in turn, may result in poorer outcomes and
increased number of patient safety events. Improved clinical outcomes
are known to result from collaborative care planning (Craven et al,
2006).

We aim to increase patient safety by promoting collaborative care
planning between staff and patients in acute inpatient psychiatric
settings. Collaborative care planning can be encouraged through a
relatively simple framework utilizing a Two-Step Comfort Toolkit, which
will be described below in the ``Practice Plan'' section. This framework
gives tools for staff to work with patients and their supports to build
skills for both evaluation and management of emotional distress, which
often precede patient safety events.

\par\null

\section*{Leadership Plan}

{\label{662980}}

\begin{itemize}
\tightlist
\item
  Provide infrastructure. Use the Two-Step Comfort Toolkit to
  systematically build patient and support skills development in an
  effective and efficient manner. Collaborative care planning appears to
  have particularly strong effects in patients with more severe
  disorders, and even low levels of collaboration can have positive
  outcomes (Craven et al., 2006). This is particularly important in
  acute inpatient psychiatry settings, where psychiatric severity tends
  to be high, and staff often are time and resource constrained (Porter,
  1992).
\item
  Provide scope. Develop a guide for staff and physicians to determine
  appropriate family and supports to be involved in care planning.
\item
  Provide capacity. Protect time to engage in patient comfort planning.
\item
  Provide capability. Educate staff on how to leverage comfort planning,
  how to engage patients to identify their triggers, and when to seek
  additional resources.
\item
  Provide motivation. Highlight the importance of patient involvement in
  patient outcomes, empower staff to take action to proactively assess
  and include patients in their treatment.
\item
  Provide outcomes. Systematically track and iteratively improve patient
  engagement by collecting data about outcomes, success rates, adverse
  events.
\end{itemize}

\section*{Practice Plan}

{\label{464071}}

The Two-Step Comfort Toolkit can be completed in as little as two
30-minute sessions. It should ideally be completed as soon as a patient
is settled enough to actively and collaboratively engage with the
clinician.

\textbf{Step One -- Comfort Planning (Fig.1, Fig.2)}

\textbf{Step Two~ -- Comfort Kits (Fig.3)}

\subsection*{Comfort Plan: Collaborative Creation
Guidelines}

{\label{962006}}

\subsubsection*{Introduction to client:}

{\label{641831}}

\begin{itemize}
\tightlist
\item
  A comfort plan is a way of identifying strategies you can use to cope
  with intense emotions.~ This is a plan made by you to help you feel
  comfortable and safe.
\item
  By filling out a comfort plan, both you and the staff here will have
  better awareness of:
\end{itemize}

\begin{quote}
\begin{quote}
\begin{itemize}
\tightlist
\item
  The main challenges you experience
\item
  What strong emotions look like and feel like when you experience them
\item
  How you can deal with those challenges and intense emotions; and
\item
  How staff can help
\end{itemize}
\end{quote}
\end{quote}

\subsubsection*{Fill out the comfort
plan:~}

{\label{956008}}

\begin{itemize}
\tightlist
\item
  Encourage the client to contribute as many ideas as possible and to do
  the writing, if they are able, to better gain a sense that the comfort
  plan is their own
\item
  Ideas from families and private providers are welcome at client's
  consent
\end{itemize}

For ``when a challenge happens\ldots{}what it looks like/feels like''
discuss how emotions are on a spectrum. A crisis/trauma happens when
emotions are so strong that the emotion goes outside the window of
tolerance and may feel unmanageable

For ``when a challenge happens\ldots{}what to do/how others can help''
make use of the Comfort Plan Guide (Fig. 2)~ for ideas

\begin{quote}
\begin{itemize}
\tightlist
\item
  Discuss how the more we learn what ``level'' our emotions are at, the
  more control we gain in making them more manageable
\item
  Discuss how there are things we can do and others can help with to
  manage emotions and how these strategies may be different depending on
  how intense the emotions are
\item
  Strategies may change over time and the comfort plan can be revised
\end{itemize}
\end{quote}

\subsubsection*{Discuss use of the comfort
plan:}

{\label{664876}}

\begin{itemize}
\tightlist
\item
  Client can hang the Comfort Plan on their wall or keep it in an
  accessible place to remind them of all the things they can do when a
  challenge arises
\item
  Staff will:
\end{itemize}

\begin{quote}
\begin{itemize}
\tightlist
\item
  Discuss with the patient how their plan will be used by staff
\item
  Review/update it with client after a crisis or code white as part of
  the debrief
\end{itemize}
\end{quote}

\subsubsection*{Wrap up:}

{\label{286351}}

Thank you for filling out your comfort plan. Remember this is for you to
help you feel more comfortable and safe. If it isn't working, just let
us know so that we can find strategies that do work

\par\null

\subsection*{Example procedure for an acute inpatient psychiatric
setting:}

{\label{944439}}

The Two-Step Comfort Toolkit is part of the primary nurse admission
checklist, to be initiated during orientation to the unit if the client
is settled. If the client is not able to participate at admission (e.g.,
admitted into seclusion, or sedated from medications), initiation of the
Two-Step Comfort Toolkit is postponed until next earliest opportunity.
Although primary nursing initiates the Comfort Toolkit, all disciplines
are encouraged to contribute, including Psychology, Social Work,
Occupational Therapy, and Psychiatry. Throughout a client's stay, the
Comfort Plan is updated, and the Comfort Kit is reviewed and utilized.
Sample Comfort Kits are kept on each unit, and clients may use them with
a clinician or on their own (after instruction has been provided).
Following discharge, the Community Team takes over in maintaining the
Comfort Plan and encouraging the client to create his/her own
individualized Comfort Kit.

\section*{Technology Plan}

{\label{960357}}

\begin{itemize}
\tightlist
\item
  Technology can be used to accentuate the Comfort Toolkit, but is not a
  requirement.
\item
  The Comfort Plan can be completed digitally, and tracking features
  enabled to document how many times a given symptom was noticed, how
  many times a coping strategy was used, how effective the strategy was,
  etc. This can be used to refine the list of symptoms and coping
  techniques.
\item
  Technology-enabled anxiety rating scales that would be triggered
  before and after Comfort Kit use can give valuable data about the
  effectiveness of the intervention.
\item
  Many modern smart watches have heart rate tracking features. Heart
  rate is a good way for patients to track symptoms of anxiety, build
  awareness about emotional states, and prompt use of the Comfort Kit
  when necessary.
\item
  Technology can be good grounding tools, and may be helpful in a
  grounding kit. For example, MP3 players pre-loaded with soothing
  music, handheld video games, technology guided meditation.
\end{itemize}

\section*{Patient \& Family Engagement}

The inclusion of a patient's family and/or support persons (friends,
religious leaders, private mental health clinician etc.) in a patient's
care planning while in hospital is vital to providing complete care for
the patient.~We have identified the involvement of family and other
supports as a key factor in promoting optimal patient outcomes, and
propose to:

\begin{itemize}
\tightlist
\item
  Create a conceptual model of family and support engagement in acute
  psychiatric settings
\item
  Create tools to help clinicians better assess and map out a patient's
  family and support system e.g. genograms
\item
  Provide identified family and supports with psychoeducation about ways
  to best support a patient during an acute psychiatric crisis
\item
  Develop metrics for quantifying the impact of family and support on
  patient outcomes, to contribute to the existing body of research.
\end{itemize}

\par\null\par\null



~\selectlanguage{english}
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\toprule
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\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\par\null

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\section*{}

{\label{644811}}\selectlanguage{english}
\begin{figure}[h!]
\begin{center}
\includegraphics[width=1.00\columnwidth]{figures/Comfort-Plan/Comfort-Plan}
\caption{{Comfort Plan Template
{\label{529500}}%
}}
\end{center}
\end{figure}

\par\null\selectlanguage{english}
\begin{figure}[h!]
\begin{center}
\includegraphics[width=1.00\columnwidth]{figures/Comfort-Plan-Guide/Comfort-Plan-Guide}
\caption{{Comfort Plan Guide - used to assist with ideas for " when a challenge
happens\ldots{}what to do/how others can help "
{\label{570139}}%
}}
\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[h!]
\begin{center}
\includegraphics[width=1.00\columnwidth]{figures/DIY-kit/DIY-kit}
\caption{{DIY Comfort Kit
{\label{506909}}%
}}
\end{center}
\end{figure}

\selectlanguage{english}
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