Theses and Dissertations at Montana State University (MSU)
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Item A quality improvement project to bolster psychiatric advance directive utilization in community mental health(Montana State University - Bozeman, College of Nursing, 2024) Fonner, Laira Lee; Chairperson, Graduate Committee: Lindsay Benes; This is a manuscript style paper that includes co-authored chapters.Background: This quality improvement (QI) project aimed to increase Psychiatric Advance Directive (PAD) use in a community mental health organization serving clients with severe mental illness (SMI). PAD utilization has been shown to decrease involuntary hospitalization rates and associated coercive treatments, such as forced medication and seclusion and restraint for this vulnerable patient population. Local Problem: In Montana, busy clinicians rarely offer PAD education and assistance to clients with SMI. However, studies have demonstrated increased PAD utilization followed by reduced involuntary hospitalization rates for clients receiving these services from Peer Support Specialists (PSSs). PSSs are trusted employees with SMI working in outpatient mental health facilities. Methods: This quality improvement project established a repeatable PAD implementation workflow in an outpatient mental health care organization where PSSs were trained to facilitate PAD support events. Interventions: Interventions included hosting three online training workshops for PSSs followed by peer- facilitated events to offer client education and assistance in PAD completion. Event attendees were asked to complete event feedback surveys. Results: All invited PSSs attended one of the three online training workshops (n=X). X clients attended peer-facilitated events of X invited. Only two clients completed documents during the peer- facilitated events. Five clients started documents and wished to complete them later. None of the attendees completed event feedback surveys. Conclusions: The project successfully increased PAD awareness and utilization for PSSs and clients with SMI. The project team successfully established a repeatable workflow to bolster PAD use and generated organizational enthusiasm to continue utilization efforts.Item An improved approach to screening of eating disorder risk in a pediatric psychiatric care facility(Montana State University - Bozeman, College of Nursing, 2022) Smith, Christopher Scott; Chairperson, Graduate Committee: Molly SecorEating disorders (EDs) have emerged as a prominent but underrecognized problem in the pediatric population from lack of screening. Reviewed were multiple screening tool options for risk of EDs to utilize in the admission assessment at a pediatric psychiatric care facility, resulting in the use of the Sick-Control-One-Fat-Food (SCOFF) questionnaire. Additionally, screening on admission was moved from nursing staff to that of the project's population--the medical group of nurse practitioners (NPs) who facilitated referrals based on results. The goals of this quality improvement project included a 100% screening rate for all patients aged 6 to 18 years admitted to the facility and a subsequent 100% referral rate for all positive screenings to psychiatry and the registered dietitian. These changes were implemented at the facility over eight weeks with weekly data collection and analysis comparing weekly census reports to SCOFF screened admissions and positive screenings to the number of referrals made. Every two weeks in the implementation, Plan-Do-Study-Act (PDSA) cycles were used in meetings with the medical group NPs to address and overcome barriers in implementation. The results showed overall improved screening rates, but the goals of 100% screening and 100% referral rates were not met. An average of 88% screening rate and 85% referral rate for positive screenings were achieved. Findings of this study inform future practice to utilize a risk for EDs screening tool that is valid, reliable, brief, and easy to score implemented in similar populations. Additionally, more time should be allowed in implementation--at least 12-weeks to allow for more data collection and PDSA cycle completions.Item Improved suicide risk assessment screening in a youth treatment facility: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2022) Sell, Carly Ruth; Chairperson, Graduate Committee: Tracy HellemResearch suggests that youth receiving mental health treatment are at increased risk for suicidal ideation or suicide attempts. Thus, youth admitted to a psychiatric treatment facility must receive appropriate suicide risk assessments. The Columbia-Suicide Severity Rating Scale (C-SSRS) is a well-researched, evidence-based, tool which has been endorsed by multiple agencies, including The Joint Commission, as an effective instrument to screen for suicide risk in youth populations. This quality improvement project aimed to improve the overall safety of patients admitted to the designated clinical site by implementing a standardized suicide assessment screening process using the C-SSRS as the identified screening tool. The Model for Improvement was the framework chosen for this quality improvement project. The clinical site selected was a licensed therapeutic group home and school specializing in relational-based trauma-informed care, treating children and adolescents aged 5 to 15 years. Five licensed therapists and one registered nurse received formal training to administer the two identified versions of the C-SSRS. Data pertaining to completion rates for assessments and interventions implemented per protocol were collected over three PDSA cycles. 100% (n=19) of baseline and admission assessments were completed and documented in the EHR within 24 hours of assessment completion. Additionally, 100% (n=19) of the patients assessed completed a safety plan as part of the organization's identified suicide risk-reduction interventions. During the data collection period, no patients presented with possible suicidal ideation, and no patients screened in the "high-risk" category. Therefore, no data were collected related to these objectives. This quality improvement project aimed to improve the overall safety of patients admitted to the designated clinical site. Despite several limitations, all patients received baseline suicide assessments and completed a safety plan. The long-term hopes for this process change include improving the ability of clinicians to accurately assess suicide risk and intervene appropriately, leading to fewer patients presenting with suicidal behaviors and overall improvements to patient safety.Item Integrated behavioral healthcare: examining barriers and facilitators to referring clients virtually in a rural primary care clinic(Montana State University - Bozeman, College of Nursing, 2023) Madson, Christian Ghilliam; Chairperson, Graduate Committee: Margaret HammerslaRural primary care providers are considered the first line for behavioral health and substance use disorder (SUD) treatment in Montana, which is designated as a Mental Health Professional Shortage Area (MHPSA). Virtual integrated behavioral health (IBH) is one approach primary care organizations use to support the efficient use of behavioral health resources. This quality improvement (QI) project aimed to examine barriers and facilitators to a current virtual IBH program at a rural Montana primary care clinic. During the pre-project process mapping and narrative member checks, areas of opportunity for improvement were identified. Areas of potential improvement included access to a warm handoff workflow, a desire for a behavioral health scripted communication tool, and modifications to the mood and SUD screening process. Surveys and narrative data from staff were collected weekly and informed ongoing changes to the IBH process, the scripted communication tool, and the mood and SUD screening process. An IBH "super user" was identified and accepted the role. The project resulted in a staff-approved warm handoff workflow and scripted communication tool and the emergence of an unexpected barrier to the IBH process: differences in the lived experiences of salaried versus hourly staff and their impact on the diffusion of change within the organization. The findings of this QI project demonstrate the importance of organizational buy-in among stakeholders and its importance to the success of collaborative projects. Electronic health record (EHR) documentation of mood and SUD screenings, inclusivity in design methods, and recognition of power differentials are recommended to create and sustain workflow and process modifications.Item Implementing signs of suicide program and Columbia-Suicide Severity Rating Scale in a school-based setting: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2023) Kellam, Mariah Swank; Chairperson, Graduate Committee: Molly SecorIn Montana, the youth suicide rate is more than double the national rate. Signs of Suicide (SOS) is one prevention program that is utilized within the school-based setting to educate middle and high school students. In a rural Montana school, the Brief Screen for Adolescent Depression (BSAD) is administered in conjunction with the SOS program to screen for depression; however, no focused suicide risk screening protocol exists. A Plan, Do, Study, Act cycle was implemented throughout 6 weeks to screen middle and high school students for depression, introduce subsequent suicide risk screening, and refer to mental health professionals as indicated. The school counselor (SC) performed SOS/BSAD, then subsequently collected Columbia-Suicide Severity Rating Scale (C-SSRS) scores, made referrals, and followed up as necessary. All data were de-identified and entered into an excel document before analysis and dissemination by the DNP-S. One hundred percent of high school and middle school students (n=144) participated in the SOS program and completed a BSAD. Of 20 identified as high-risk for depression, 11 completed the C-SSRS. Of those 11, three were identified as at-risk for suicide. All three students had completed referrals with a mental health professional. Follow-up C-SSRS indicated an ultimate reduction in suicide risk. The project effectively identified students at risk for depression and subsequently evaluated suicide risk and closely tracked completed referrals. Future research should evaluate long-term changes in C-SSRS scores over time post follow-up with mental health professionals.Item Improving the care continuum following discharge from a critical access hospital due to a mental health crisis(Montana State University - Bozeman, College of Nursing, 2022) Truesdell, Melinda Marie; Chairperson, Graduate Committee: Yoshiko Yamashita ColcloughData shows that in the first week post-discharge from the hospital following a psychiatric crisis, a person is 300 times more likely than the general population to die by suicide (Chung et al., 2019). Access to outpatient mental health treatment in the week following discharge from the hospital due crisis is an evidence-based intervention measured by the National Committee of Quality Assurance (NCQA) that saves lives. Rural populations have an additional risk of death by suicide due to multiple factors that limit mental health care access. Engaging patients while they are at the hospital with a mental health specialist and scheduling an appointment for outpatient mental health treatment are essential bridges in the mental health care continuum. This DNP project highlights a workflow process in which the hospital peer support specialist communicates with an outpatient mental health clinic crisis care coordinator about patients in need of post-discharge services following a mental health crisis. Through this interdisciplinary process, patients were provided with an outpatient appointment within seven days following hospitalization. The DNP student tracked appointments made for and kept by patients following hospitalization. Although the results were too small for meaningful analysis, lessons learned provide valuable experience for future mental health care coordination quality improvement projects. Limitations include a short six-week implementation timespan and COVID-related influences.Item Evaluating provider opinion of telepsychiatry(Montana State University - Bozeman, College of Nursing, 2021) Brannen, Hilary Jane; Chairperson, Graduate Committee: Tracy HellemTelepsychiatry, or two-way video conferencing for psychiatric purposes, has been around for the last 60 years. However, full implementation of its usage has stalled. Research has shown that clinical outcomes and patient satisfaction are equivalent to or superior when utilizing telepsychiatry, but provider satisfaction is lower. The aim of this project was to initially survey medication providers of psychiatric services at a statewide community mental health center in Montana to determine barriers that may exist to implementation and then provide education to determine whether that would impact their overall opinion of the modality. However, during the time between initial survey and follow-up survey, the COVID-19 global pandemic occurred and forced all providers to utilize telepsychiatry exclusively to continue providing care. This driving force of change allowed for the providers to increase their overall opinion of the feasibility, benefit, and confidence and belief in the modality. Continued challenges were noted but an overall increase of knowledge about telepsychiatry was also found. These findings are encouraging for increasing utilization of telepsychiatry by providers to provide access to mental health services in more rural and underserved communities.Item Introducing trauma-informed care in an acute inpatient psychiatric unit: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2020) Thompson, Evan Robert; Chairperson, Graduate Committee: Julie RuffTraumatic experiences are common in society and are associated with an increased risk of development of adverse physical and psychological outcomes extending throughout the lifespan. Individuals accessing mental health services, such as inpatient hospitalization, are likely to have experienced interpersonal trauma at some point during their lives. Mental health professionals are well suited to provide supportive and effective trauma-informed care (TIC) to patients with trauma histories. TIC seeks to actively resist patient re-traumatization and caregiver secondary traumatic stress. An evidenced-based trauma-informed care training was presented to mental health professionals working on a psychiatric inpatient unit. The project involved a single group pre-post test design with a 1-month follow-up assessment. Staff attitudes towards trauma-informed care were evaluated by a psychometrically validated tool (ARTIC-35). Sums of the items on the ARTIC?35 for each participant were divided by the number of items, means and standard deviations for aggregate average scores for each time point were obtained, and percent change for participant average scores between time points were calculated. Additionally, participants were asked to share if they had incorporated trauma-informed care into their work with patients and if they experienced any barriers to implementing TIC since the training. Immediately following the training, ARTIC-35 scores increased on average by 11%, demonstrating that attitudes related to trauma-informed care improved as a result of the training. One month following the training, all six participants maintained their score on the ARTIC-35, representing a 12% increase from pre-training scores and 0.61% from immediately following training. Further, all participants indicated at the 1-month follow-up assessment that they changed their practice to incorporate trauma-informed care into their work with patients. A 1-hour TIC in-service training demonstrated the ability to improve psychiatric healthcare professional's attitudes toward trauma-informed care. Healthcare organizations serving patients with traumatic histories should consider TIC training for all personnel.Item Breaking the cycle of adverse childhood experiences: a program evaluation(Montana State University - Bozeman, College of Nursing, 2019) McAnally, Jennifer Lyles; Chairperson, Graduate Committee: Dale MayerAdverse childhood experiences (ACEs) are specific types of childhood trauma, that, when experienced, have been found to have dose-response relationship to poor health outcomes later in life, namely, many of the leading causes of death in adults. ACEs include psychological, physical, or sexual abuse, witnessing violence against the mother, living with household members who were substance abusers, mentally ill or suicidal, or who are imprisoned. Recognizing a need for intervention to disrupt this ACE to illness trajectory, The American Academy of Pediatrics has called upon medical providers to address ACEs through screening and community-building. Since there is currently no guideline for how to address ACEs, the purpose of this scholarly project was to evaluate the Lewis and Clark County Health Department (L&CHD) ACE program for effectiveness and alignment with evidence-based practice. Using the Centers for Disease Control and Prevention manual titled Introduction to Program Evaluation for Public Health Programs (IPEPHP), an evaluation was completed. Steps included engaging stakeholders, describing the program, developing an evaluation plan, gathering credible evidence, and analyzing the evidence in order to develop conclusions and make recommendations. The L&CHD ACE program was found to be a largely progressive model that is consistent with most program goals and literature. Those who participated in the program tended to complete the program successfully, however, a majority of those who were referred to the ACE program either chose not to take advantage of the referral or declined to participate in the program. This finding was unexpected and warrants further inquiry. It appears that an integrated behavioral health model may be more effective for engaging potential participants, where they are able to initially meet with mental and behavioral health experts in the familiar primary care setting.Item Presentation of a comprehensive community suicide prevention program: improvements for young adult males ages 18-34 years old(Montana State University - Bozeman, College of Nursing, 2019) Bagley, Jamie Lynn; Chairperson, Graduate Committee: Maria WinesSuicide continues to be a worldwide phenomenon causing more than 44,000 deaths nationally (American Foundation for Suicide Prevention [AFSP], 2015) and 800,000 deaths globally (World Health Organization [WHO], 2017). Although any population can be affected by suicide, certain populations are at a higher risk of being impacted. Completed suicides by the male population have been rapidly accelerating both nationally and within the state of Montana. Over the last 40 years Montana has been in the top five states for the highest suicide rates in the nation (Montana Department of Public Health and Human Services [MTDPHHS], 2016b), and as of January 2018, Montana ranked first in the nation for highest suicide death rate (Centers for Disease Control and Prevention [CDC], 2018). Male youth suicide is rising and is now the second leading cause of death between males ages 15-34 years old (CDC, 2015). Butte-Silver Bow County, located in Montana, is no exception, and is one of four counties in Montana with the highest suicide rates of 20.6/100,000 compared to Montana's suicide rate of 16.4/100,000 (MTDPHHS, 2016a). Twelve percent of males in Butte-Silver Bow County report 'fair' or 'poor' mental health (Sisters of Charity of Leavenworth [SLC], 2015). There is significant need for mental health support services for this age group. The lack of evidenced-based suicide prevention interventions/programs for males, particularly male youth, is alarming. The goal of this proposed community implementation program is to provide Butte-Silver Bow County and future communities with evidence-based interventions to decrease male youth suicides. An exhaustive literature search was conducted, and evidence-based suicide prevention programs were evaluated. As a result, evidenced-based components from Problem Solving Therapy (PST), and The Collaborative Assessment and Management of Suicidality (CAMS) were combined to form one comprehensive suicide prevention intervention program.