Interview with Isaac Abraham, RN, MSN, senior consultant with Compass Clinical Consulting, by HcPro Medical Staff Senior Editor Matt Phillion.

With CMS and The Joint Commission increasingly pushing to make sure facilities are following requirements and standards regarding mental health, now is a good time to assess your own facility’s mental health resources. But what happens when you’re in a facility without a behavioral health services unit? How do you keep patients and staff safe?

You have to start right when the patient arrives at the hospital, says Isaac Abraham, RN, MSN, former senior consultant of Compass Clinical Consulting.

“You want to make sure you involve the patient throughout the entire continuum of care,” says Abraham. “It starts with admission.”

Abraham recommends working with staff to engage with the patient to get to the heart of their story.

“We recommend this, particularly if the person is someone we’ve seen before, what I call a frequent flyer,” says Abraham. “A lot of time you can pick up on additional stressors or other factors that make this new admission different.”

And it’s not only beneficial to the patient to realize if there are some new factors in their latest visit to the hospital—you’ll need to make sure it’s part of the patient’s Plan of Care.

“The Plan of Care—and this is where I see issues— has to be relevant to the assessment you’ve done on the patient,” Abraham says. “It has to be a plan you’ve worked out with the patient or their loved ones.”

It begins at admission but carries through until the patient leaves the hospital and beyond—something most professionals know, but may not always follow through on.

“The continuum of care is scrutinized now more than it has ever been in the past,” says Abraham.

The big issue Abraham is encountering that comes into play with behavioral and mental health is the increased focus by The Joint Commission and CMS on patient rights.

“We’re doing better as a country, but a lot of times patients are labeled as behavioral health patients, ” and issues arise, Abraham notes.

As recently as a few years ago, use of restraints without legitimate reason was still a common practice, something that The Joint Commission and other regulatory requirements improved.

“If you use restrictive methodology you have to be justified in doing so,” says Abraham.

To comply with these standards, Abraham works with organizations with training, particularly in the emergency department (ED), labor and delivery, and other areas where mental health patients are frequently seen and can quickly become a risk to themselves and others.

“Staff tell me they don’t feel comfortable, that the training they’ve received in school [for dealing with behavioral health] wasn’t hands on enough. So we coach them on how to deal with behavioral health patients,” says Abraham.

Now, he says, all healthcare facilities have to take the time and effort to train staff to make sure they have the ability to prevent, and when needed, de-escalate behavior.

“This is an expectation from CMS and The Joint Commission,” says Abraham. “You use the least restrictive methodology when working with any patients, especially psych patients. You have to make every effort to keep the patient as well as others safe. Restrictive methods should be used only as a last resort and documentation should reflect the process.”

Of course, while the emphasis across the country has been to eliminate or reduce the use of seclusion or restraint, this requires a combination of resources, support from leadership, and training to properly implement.

“The organization must have the reduction of seclusion and restraints as part of their vision and mission to create a safe environment. This is being done across the country,” says Abraham.

When visiting organizations, Abraham starts by doing an assessment of the units, looking at how the teams work together. He says the best places have the same philosophy to behavioral healthcare.

“We’re not doing it for The Joint Commission or CMS, we’re doing it for the patient,” Abraham says.

The organization needs to have a vision that is understood and supported by everyone.

“If you start off there, every meeting should begin with what is our vision,” says Abraham. “And you have to keep that fresh in staff members’ minds.”

Leadership buy-in can make the training process easier through support both financial and cultural. Leaders need to be at the forefront of improving the facility’s culture of safety.

“We train staff on how to hold a patient or restrain them, and that’s important to keep them safe—but if you can prevent it from happening at all, that’s better,” says Abraham.

A common theme with behavioral health and the continuum care is what happens once the patient leaves the facility. Without proper discharge planning and follow-up, behavioral health patients can get looped into a cycle of readmission.

“Patients come into the hospital and haven’t been taking their medication. You get them back on that medication regimen. This goes for all health issues, not just behavioral,” says Abraham. “If I don’t take my insulin, my diabetes will get out of control. The same holds true for psych patients.”

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