Bill Klaproth (Host): This is a special episode of Today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership.

Recorded live at the AONL 2024 conference. I'm Bill Klaproth as we talk about empowering nurses to complete same day access mental health appointments. With me is Tammy Marquez de la Plata, Chief Nurse Mental Health at South Texas Veterans Health Care System. And we have Shayla Flemings, Nurse Manager, Outpatient Mental Health, also at South Texas Veterans Health Care System.

I want to welcome you both to our podcast booth at AONL 2024. Shayla, welcome.

Shayla Flemings, BSN, RN: Hi, Bill. Glad to be here.

Host: Yeah, it's great to have you here. Tammy, welcome.

Tammy Marquez de la Plata, MSN, RN, NE-BC: Hey, Bill, we're so excited to meet with you today.

Host: Yeah. So happy for you to be here as well. So Tammy, let me start with you. Can you tell us about your session and why you wanted to address same day access to mental health care?

Tammy Marquez de la Plata, MSN, RN, NE-BC: One of the things that we want to do is really mental health care is everyone's business. And what we're trying to do is provide early interventions before patients come in crisis. And when you have same day access, patients know that they can immediately come in and be seen for services and so they can be screened for suicide at early intervention so that interventions can be provided early.

What that has done is really empowered patients to kind of take ownership over their mental wellbeing because they know they can access appointments at any time. They might see a nurse and come in just to speak to somebody. They might need med refills. They might need to get access to one of our programs and it's really important that they're not waiting for weeks for these type of appointments.

Host: So the goal is when someone needs mental health care access, you're able to provide that right away. That's when it's needed now, not two weeks, or next Tuesday.

Tammy Marquez de la Plata, MSN, RN, NE-BC: Right. Because you know everybody in patients even without a mental health diagnosis have days where they're mentally unwell and I need to talk now. So let's say we had something very terrible happen at work or we lost a pet. I don't want to talk about that I lost my pet two weeks from now. I'm grieving in the moment, right?

Or something, I got demoted at work. I need immediate intervention, somebody to talk to, somebody that can listen and provide some goals and give me a plan of care right now, not a week from now, not two weeks from now, but when I'm feeling the emotions that I am.

Host: So when you say mental health care is everyone's business, is that kind of your motto inside the walls at South Texas Veterans Health Care System?

Tammy Marquez de la Plata, MSN, RN, NE-BC: One hundred percent. We like to say is mental health is everybody's business and there's no wrong door to same day access. So if you were to walk into a primary care clinic, you are going to be able to see somebody for mental health care needs. If you walk into a mental health care clinic, you will be able to see someone for your mental health needs.

Ortho. Most people, when you break a leg, there might be some mental health care associated with that because maybe now you can't go back to work and you're really worried about that. So, there is no wrong door, because it's everyone's business.

Host: There's always a right door. It seems like this is common sense. It should be like this all, all time, right? Same day, mental health care. So Shayla, how did you put this program together? How did you go from, instead of people having a door shut in their face to having that door open all the time? How did you change this?

Shayla Flemings, BSN, RN: Well, so initially, same day access was nurses triaged the veteran, and then providers saw all of the patients. So, that kind of tied and boggled down the provider to having to see all these patients, and sometimes they didn't need to see a provider. And honestly, when we looked at the numbers, it was probably more 98, 99 percent didn't need to see a provider.

A nurse could be empowered to see that patient and close out that visit without having the provider having to have allotted time. So what we did was first, of course, empower our nurses, but change is not easy. It is hard. And so, kind of pre implementation, we have huddles every day.

And so we utilize that to have, like, nurses concerns about it. You know, what do you think? What do you think the barriers may be? Trying to just get kind of problems so we can then problem solve before the implementation. So we did that and I would like to say that we did absolutely amazing and we had a lot of buy in. However, we had equal amounts of pushback because as is change is difficult.

So, while when we initially implemented it, of course, we kind of circled back because we had some follow up that we needed to provide. Because, you don't know what you don't know. So as you implemented it, you, we realized, oh, well, that's a problem. Let's figure that out. And one of the things was when you have mental health and you have no wrong door, you have established patients and unestablished patients.

So you have patients that are already established within the mental health clinic. And you can, we can reach out and say they need a med refill. We can just sign a provider to a note. So within 24 to 48 hours, they can reach out to the veteran to refill that prescription. But then the caveat to that is we have unestablished patients that have no, that have not initiated any mental health care.

And so now we're seeing a patient that has never seen mental health, that maybe needs new meds, needs therapy, and doesn't know how to start that. So what we did was we empowered nurses to initiate that. We talked to them. So there's a website that's great throughout the VA that we can, they can print out coping mechanisms or how to deal with anxiety or different things like that in the moment.

And then we'll send a message to provider to put that consult in. So then they have an appointment. We also had an interdisciplinary kind of team help with the algorithm and our PharmDs were able to do same day appointments, really quick appointments, if they needed some meds, like non stimulant meds, to bridge through from that day to their actual appointment date.

And so that really helped the unestablished patients because now they're, we've brought them into mental health. So they don't feel like they just, well, this is too hard, my appointment's not until months and months later. I don't want to do this because when you're mentally unwell, you kind of reach out once.

And if you have a door closed, then you're done. And so this isn't kind of like a medical issue where you're like, ooh, this pain is nagging. You're like, well, I'm just going to deal with it. And so, we empower the nurses to close out the appointments and have the veterans leave with a plan. So maybe we're not refilling your prescription at this exact moment, but your provider will be contacting you within 24 hours to get that ref, that prescription refilled, and it can be mailed or you can go to the clinic if you need that with a consult.

So we can provide them with whatever we can. The nurses will sit and talk to them if they're having an issue, like their dog passed or they're going through a divorce, and then we can send a consult, but we can provide them with resources to help in the moment. And then they'll get a consult to be able to go to therapy or counseling or anything like that.

So, it was really the pre implementation, the implementation, and then continuous follow up. Because you get stuff where you're like, oh, well, this person came in for that. And you're like, oh, oh, I didn't, okay, let's, like, okay, let's figure out what this issue is. And so, it's kind of just continuous follow up as well.

Because today there might be an issue that wasn't there yesterday. And so, within that, we have to figure out, okay, well, what's the plan if another veteran like this, or in the moment, this veteran is here, what do I do? So it's continuous follow up to that.

Host: Yeah, that's really uh, interesting and I like

when you basically said, closing a door when some, in someone's face when they're at their most vulnerable is not the best time to do that because then they probably walk away going, nobody cares about me, I'm all alone.

Shayla Flemings, BSN, RN: Right.

Host: Just proves it. So, that's why important when they reach out, like you said, when they reach out for help, that one time you better be there to accept them.

Shayla Flemings, BSN, RN: Yes, absolutely. No wrong door. Any door you walk in, we're here with open arms to figure out like, what's going on? What's your issue? Let's find you a solution. Let's, have you leave with a plan.

Host: Empowering nurses. Not always having to see the provider. Maybe that person might just need somebody to listen to them at first. To calm them down or let them feel heard could be what they need in that moment. And then, okay, you kind of stabilize them and then make, okay, they're good to see a provider in couple of days or

Shayla Flemings, BSN, RN: Absolutely.

Host: So, Tammy, what are some of the first steps for someone listening to this saying, oh, I like this, I like this no wrong door policy. How do you start something like this?

Tammy Marquez de la Plata, MSN, RN, NE-BC: I think you need to engage your frontline nurses at the very beginning. To one, make them feel empowered that we have a scope of practice. We can provide nursing led psychoeducation. And we're able to screen for suicide. And we're able to provide that care. Nurses are at the bedside all the time, they're in the clinics all the time, and they really provide the majority of the education, so they're capable of developing a treatment plan.

I don't want to discredit our providers in any way, but nurses are the eyes and the ears of the hospital, and we're the ones who translate that information to the providers. So, why do we need to translate it when we can just take care of it in the moment? So, it's really important to get your buy in from your nurses, so that they can give you the barriers ahead of time.

So that when you're developing the framework for setting up a clinic, you're addressing those, so that it's just a little smoother when it goes into full operation because you don't want the nurses to come back and say, well, I told you this wouldn't work. And they will. And that's okay. You're like, well, you know what? You're right. It's not working. So let's adjust the algorithm again. And we had to adjust the algorithm multiple times because things came up and we're like, you're right. It's not working. Let's change it. We have to. They have to know that we're listening to that, that we're not just telling them what to do, we're doing this together.

Host: More of a collaborative process. So, as you said, get the buy in from the nurses. Was there initial pushback at all, Shayla?

Shayla Flemings, BSN, RN: Absolutely. I think um, we did have buy in from nurses equal parts, some pushback, because, I mean, again, like I said, change is hard. But also, I think they just saw all the issues that could arise. And, well, you know, I think that one of the biggest things was, well, sometimes we're there for an hour, and the doctors aren't there for an hour.

And I'm, well, if you have a med refill, and then they see a psychologist, and said they, well, they can't, they can also not refill their medication. So they're doing something different. So, I contacted a psychologist to see, hey, what do you guys do for your visits. Like, let's see if we can just implement what they utilize, because nurses they care, and they want to, solve all of this person's issues in this short amount of time that they have, and that's just not possible.

So, I think closing the appointment was huge especially after the initial implementation, we realized, like, they weren't closing. They were just like, I mean, you know, like, this person might be 65, and they're like, well, when I was 18, and they're here for a med refill, and so they're there for an hour and a half, and so, I think that one of the biggest things that psychologists said was set the expectation at the beginning of the appointment for the veteran, because you want a med refill.

Hey, you know, I see your issue is you would like to get a med refill, let me see what I can do, let me contact your provider, let's get that going for you, so they understand this is what I'm going to do for you, and it's not completely open. And, you just kind of state their needs and then address those needs versus just having it open for, you know, y'all to hang out for half a day.

So, I think closing was the biggest issue and after we had Lunch and Learns we were able to help that. And also, I think it was good to have a Lunch and Learn when it was an open discussion. So, we had the nurses that bought in and the nurses that didn't. Because it's easy for me as a leader to say, hey, this is going to be great, you can do this.

And then it's not great, and they're like, well, you don't know. But if someone that's doing the exact same job as you says, Oh, well, you know what? Absolutely, we can do this because XYZ. You're like, oh, okay. And so that was really important to get those frontline nurses to actually communicate together to see like, Oh, okay, well, maybe that solution will help.

And also, I even went to do some of the same day visits. Well, let me see if this works. Let me see what we can do. Like, I know that there's issues. You know, I'm also a nurse. And so I'm like, let's do some of those same days. Let me do them. Let me see how it, goes, what issues I might have. So I can kind of pick apart, you know, a few things in real time. So I know, and I'm not just hearing it secondhand.

Host: Right, and then you said follow up is really important as well.

Shayla Flemings, BSN, RN: Absolutely.

Host: So, yes, just to make sure if they are on meds that they are keeping up with it. If they are coming back to their appointment, if they do have regular appointments, that follow up is important, that execution after that. So Tammy, how have the results been? Tell us.

Tammy Marquez de la Plata, MSN, RN, NE-BC: So, access to care is really a global problem. Patients getting access to mental health care. And what we've seen is by nursing completing these appointments, we actually, in one clinic alone, we're able to free up 400 provider hours. Which means that providers now have that amount of time where they can do intakes, where they can be doing DBT therapy, CBT therapy.

They can be doing other things to see patients. So by nurses completing these appointments, providers are having these appoint free time so that they can get more schedules in, get more patients in, and so we had about a greater than a 30 day wait for some of our consults to be addressed and then we would have to send those out into the community because you're not going to get your first appointment for six weeks.

Well, that's not viable in mental health. So we were able to free up this provider time, keep the patients from going into the community and keeping them in the Veterans Healthcare System. It improved continuity of care and just access and timeliness to their next therapy or provider session.

Host: So it sounds like there's an ROI to this as well.

Tammy Marquez de la Plata, MSN, RN, NE-BC: Yes.

Host: Yeah.

Tammy Marquez de la Plata, MSN, RN, NE-BC: Big return on investment.

Host: Yeah, which I would imagine uh, your leadership appreciates as well. That's an important factor to this, too. Well, this has really been fascinating. Thank you for sharing your thoughts on this. We really appreciate it. As we wrap up, I'd love to get final thoughts from each of you.

Shayla, anything else you want to add about this program?

Shayla Flemings, BSN, RN: I think just not in this program, but in general, when you're implementing anything, especially with nursing, I think empowering nurses to understand that sometimes they can, their scope isn't just what they do in their job, their scope is expanded and they don't realize it. So empowering them to know, like, you can do so much more and you can help so much more and it actually is rewarding on the back end when you know these veterans are, and it could be any patient, is really like speaking to you because they know that you care and you've actually helped solve their problem. So I think empowerment of nursing or staff in general is huge in implementing anything or starting anything new.

Host: Yeah, great thought. Thank you for sharing that. And, Tammy, final thoughts from you?

Tammy Marquez de la Plata, MSN, RN, NE-BC: Final thoughts are people like to say that mental health is not my job. I'm not a mental health nurse. But at the end of the day, every nurse is a mental health nurse. We provide comfort, we provide caring and it doesn't matter if you're at the bedside. It doesn't matter if you're in the ICU. We're active listeners and we're empaths and we have emotional intelligence.

So mental health is everyone's job. There is no wrong door, again, to mental health. And I know I said that earlier, but there's no wrong door to mental health. Just be an active listener for your patients and really that's the first step of anything.

Host: Yeah, I love how you said that. Again, mental health care is everyone's business. And I love your philosophy, no closed door. I think that's awesome. When they need help, you are there to provide it. I think that's really cool. Well, thank you both for coming by today. I appreciate it.

Shayla Flemings, BSN, RN: Thank you so much for having us.

Tammy Marquez de la Plata, MSN, RN, NE-BC: Thank you, Bill. It was really nice meeting with you today. We appreciate it.

Host: You bet. Once again, that is Shayla Flemings and Tammy Marquez de la Plata. And for more information, please visit aonl.org and if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Today in Nursing Leadership.

Thanks for listening.