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Q&A with the 'hospital fixer' charged with saving the Alaska Psychiatric Institute

Alaska Dispatch News - 3/16/2019

March 16-- Mar. 16--In February, Alaska officials turned over management of the state's sole psychiatric hospital to a private company. After years of mounting problems, the Alaska Psychiatric Institute was on the brink of losing crucial certifications and facing at least three investigations that found major errors threatening patient safety.

The no-bid contract put Wellpath -- a Nashville, Tennessee-based company -- in charge, at least until July. According to the terms of the state's contact, API would be fully privatized after that if Wellpath meets benchmarks including opening more beds and getting the hospital out of its regulatory problems.

One of the people charged with turning API around is Kevin Huckshorn, a nationally known consultant whose specialties include making rapid, major changes at distressed hospitals. Huckshorn, who began her career as a mental health nurse, is also known for her expertise on reducing the use of seclusion and restraint.

In the midst of a busy day of training staff at API, she sat down for an interview with ADN. She would not answer questions about the corporate aspects of Wellpath, nor about the controversial no-bid contract that led to the company's involvement with API. But she did talk about problems and solutions at API, what she thinks about the importance of a concept called "trauma-informed care," whether she thinks the state needs a separate forensic hospital for criminal defendants, and how people should view her company's history, among other topics.

This conversation has been edited for clarity and length.

ADN: How would you place API and the problems at API in broader context? How does it compare?

Kevin Huckshorn: One of our specialties is to go into troubled hospitals and help fix them. I find API in the same boat that we've found a number of other hospitals we've gone into. On a scale of 1-10 -- well, it's serious.

They almost lost their certification. In terms of seriousness of the findings from (the Centers for Medicare and Medicaid Services), the ombudsman's report and OSHA, it's serious. It's patient care and life and health. If you don't fix those kinds of serious issues, people will get very hurt, whether staff or patients.

In terms of fixing it -- with a really strong leadership team, there's a good cadre of staff here who are, from what I can tell, anxious, willing, able and competent to get on board and start fixing everything. It's not rocket science. It's doable. Very doable.

ADN: What are your top priorities -- the things that immediately need to be fixed? And what are you doing to fix them?

KH: First top priority was to review all the regulatory findings. Centers for Medicaid and Medicare, The Joint Commission (a hospital accrediting organization), the ombudsman's report, OSHA report. The first thing was to get a really good handle on the findings and put together a corrective action plan.

In terms of the findings, we've got everything from overuse of seclusion and restraint, lack of reporting of adverse events, lack of documentation of adverse events, training and competency issues, in terms of practice. Obviously there's some disconnect between leadership and staff on the units.

We're looking at a 50 percent reduction in operation capacity -- I mean, going from 80 beds to 36 beds is a huge issue when this is the only state hospital in Alaska, serving the entire huge state. That's a significant issue. A lack of staff in key leadership and clinical positions. Having identified those issues, we put together a 400-point transition plan. It's divided into chapters.

We go in and chunk down all the different departments and divisions of a hospital system. We chunk it down into actual tasks. What does the department of performance improvement actually do? So we now have a 400-point transition plan, divided into administration, clinical services, IT, human resources, policies and procedures, communication, everything is divided. Everyone has been assigned tasks, with due dates.

One thing is to go through all the job descriptions -- a job description is a work contract, right, with a staff member. You can't expect things that aren't on their job description. So we're going through those to make sure they are current and they identify all the competencies that person needs to have.

For a RN not only do they need to meet the minimum requirements to hold a nursing license, but they also need to be competent in a trauma-informed approach, in a recovery-oriented system of care. Understand what evidence-based practice is. Do the different specific behavioral health assessments we do. And they need to, most importantly, know how to manage a unit, especially with regard to preventing conflicts and violence that lead to hands-on uses of seclusion and restraint, which is one of the findings of all of those regulatory agencies.

What you do is you implement an evidence-based practice, six core strategies to reduce violence and conflict that lead to the use of seclusion and restraint.

Pieces of that are a trauma-informed approach, include very specific roles of leadership. Part of that has to do with data -- how are we using data? Every single unit and every single staff person should know exactly how much restraint and seclusion they are using -- what they have been, what they are now and where they are going.

We're training the staff for the next three weeks on some core areas -- trauma-informed care, reduction of seclusion and restraint, patient rights and abuse issues. Workforce development means every single staff member is being trained to have the skills and competencies so they are becoming excellent negotiators, mediators and de-escalators.

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ADN: Was API using a trauma-informed approach before?

(They were providing an overview of trauma and what it meant in new-employee orientation.)

KH: What we know about trauma -- people who've experienced severe sexual abuse, physical abuse, neglect, exploitation, to the point where they suffer symptoms of it. Children who experience trauma in early childhood, it changes the way their brain develops. They are much more likely to startle. Much more likely to be anxious.

Everything we know about human development -- we all need to feel safe, loved, like we can trust somebody. People with serious histories of trauma kind of almost developmentally stop -- if you add to that serious mental illness, you now have people with dysregulated emotional systems and symptoms of illness who do not respond well to stress.

The whole idea (of trauma-informed care) is, at the very least, you do no harm. So when creating a trauma-informed approach, you make sure all the staff are clear that trauma is reality for the people they serve. The second thing you do is look at your environment of care and make sure you've created an environment that will not traumatize people. Meeting people's needs immediately. Trying to minimize the use of any kind of coercive methods. Implementing activities and treatment programs people want to go to, and including people in their treatment planning so it's individualized. Trying to minimize all the rules and regulations you're trying to enforce, so that people feel empowered.

I constantly talk about the real power differential: When you're admitted to an inpatient facility, you lose all your power. This is the United States of America -- we have civil rights. Behavioral health, inpatient psychiatric care, is one of the only places in America where you walk in the door and without a judge, jury or police officer, you lose a ton of your civil rights.

That's not going to make anyone feel good, especially people with serious mental illness. So people come in here; by walking in the door, they lose their ability to go where they want to go, go to bed when they want to go to bed, wake up when they want to wake up, eat what they want to eat, make a phone call when they want to make a phone call, listen to whatever music they want to listen to. We've basically taken all those rights away.

That tends to cause feelings in people.

If we add on top of that the power of staff to say "No, I'm too busy, I can't do that right now," or "No, the rule says you can't have any coffee after 10," you've created a situation where conflicts are going to happen.

The whole issue of trauma is we go in and get rid of those things. Do we really want to get in an argument if someone wants a cup of coffee at 10? Is that really worth it?

ADN: There's a massive wait list for forensic competency patients in Alaska, who are charged with crimes but determined to be too mentally ill to go through the legal process. They are held in jail while they wait. There's some real question over whether that's constitutional. What do you propose to do about that piece of it? Should we have a separate forensic hospital?

KH: I don't think you can make a decision till this hospital is running well. It would be quite possible to have two 10-bed forensic units. If it is running well, if we have the staff here to do the work, we should be able to return people to competency in 100 days. Or less. That way there wouldn't be gridlock. Right now, because a number of units are closed, our main goal is to get that all up and running and to add a number of forensic psychologists to our roster.

Because it isn't OK. You are absolutely correct -- this is almost an emergency. You can't leave people with serious mental illness in jail. They just get worse and worse.

We're working on (filling forensic psychologist) positions. We've got recruiters. They are hard-to-fill positions, but I think there's a number of ways to attract -- if this project goes forward, we won't have to stick with the state salaries. The state salaries are much less than what's competitive. We can come in as a private company, and we can be competitive.

[Alaska's system for evaluating mentally ill defendants hits the breaking point]

ADN: What is your response to people who say: How can Wellpath be owned by a private equity company and under extreme pressure to turn a profit and put the interest of patients first?

KH: Easily. First thing, as a company we're only as good as our word. Only good as our reputation. When I read some of the newspaper articles (about Wellpath), I didn't even recognize my company. I have a 40-year national reputation myself to uphold. I am very careful who I work for.

If all your work is based on your reputation when you go into a facility and you make promises and sign a contract, that's what you do. I'm not going to get into the money business, but I'll tell you this: The margin of profit is extremely low for the first couple years. Patients never want, ever. If we need more staff, we bring on more staff. If we need more food or better food, we bring on better food. We bring in more activities, more sensory modulation equipment. It's all in our 400-point plan to meet needs of patients here.

I started in 1998 with this company, it wasn't called Wellpath then -- it was Atlantic Shores, GEO Care. And we went into the first hospital to be fully privatized, South Florida Hospital. I was working for state at the time, and I remember thinking to myself, "This will either be the smartest thing I ever did or the dumbest." Because I heard all the rumors too: "(The company will) take the money and run; private companies have no business doing this work."

At the end of two years, it was the best thing I did because I saw how a private company and public-sector government could work together and the best of both worlds could come together. The private company being very nimble and the public entity saying, "These are our values." And 20 years later, Florida not only still has us running that hospital, it opened up three more. That doesn't happen when you're not providing good care.

ADN: Those hospitals have had some really serious documented problems. What happened there?

KH: Absolutely. When you treat folks with serious mental illness, you will occasionally have bad outcomes. Just like Johns Hopkins, just like Dartmouth, just like the Dana-Farber Cancer Institute.

Every single big health system in this country has had bad outcomes. They are tragic. People are generally devastated when those happen. We learn from them and you go on.

There is no perfection in health care. It's human beings trying to serve other human beings. That's the best I can tell you. It's not an excuse. We do everything possible through our performance improvement programs to identify risk factors, to mediate risk factors or to eliminate them. But sometimes things fall through the cracks and someone gets hurt.

It's the same process the FAA uses, manufacturing uses, the car industry uses: Bad things happen sometimes, and you gotta fix it and you gotta make it well or whole for the person affected and family. And you move forward and try not to ever have that happen again.

ADN: Is API a different model from most state psychiatric hospitals? It pulls people from all over the state, for short-term and long-term stays. Is that part of our problem?

KH: That's a really good question. There's a number of state hospitals in the country that provide acute care. Most provide what I call sub-acute care, where the patient has already gone into a local community mental health program or hospital, for one or two or three weeks. They are not getting stabilized, so they are moved to the state hospital for six months. Some people have what we call treatment refractory mental illness -- they don't respond as easily to treatment.

API is different. They provide services for both of those groups of people.. They provide services for people come right in off the street. Right out of court. Right out of jail or prison. And from all over the state. That's not unknown, at all. It just means you have to set up your system of care to be extremely responsive. They've done that here. They have fast admission processes. Treatment starts within eight hours, in fact assessment starts within three hours. A physician is here 24/7. I don't see that as really being an issue.

You need more social workers because you are doing discharge planning that could happen pretty quickly.

ADN: In terms of the acuity of the patients here: Are we dealing with people who are sicker? What, if anything, is different about the folks who you serve here?

KH: You have specific issues that affect the Alaska Native people. The tribes are often facing longstanding cultural, historical issues having to do with colonization, poverty, FASD, fetal alcohol syndrome, cultural issues. I'd want to really dive into the culture here to find out how do we best service this population. What are we missing culturally?

Traditional medicine isn't necessarily recognized. Traditional diagnoses are not necessarily recognized. If our goal is to engage someone in treatment and get them to trust us enough to work toward managing their illness, but they don't believe in the diagnosis, how do we engage them?

We can think about using (alternative forms of) medicine, homeopathy, to engage them -- so we can kind of mutually educate each other. We know people may not recognize medications as being helpful. But without medication, their symptoms are going to keep going. In terms of psychosis, the only thing we know to help some of those symptoms is medication. So that's a negotiation that needs to happen between staff and person coming into care. There are some definite challenges you see in Alaska you won't see in other states. All doable. You just need some care and attention.

ADN: Does our state law around involuntarily committing people and forcibly medicating people -- do those differ from other states? Are they part of a problem?

KH: No. We looked at those statutes before we came. They looked pretty similar. I think Alaska has some pretty good laws. You walk this fine pathway between a patient's right to refuse -- which is an absolute right we should all have -- and the right to refuse when you're getting sicker and sicker and sicker. And the reason you're refusing is you're not really competent to understand what's going on.

It's a horrible thing to have to forcibly medicate someone. It's horrible. It's horrible for staff, for the person. It's traumatic. But unfortunately it's sometimes necessary. I don't see anything of grave concern in Alaska laws.

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(c)2019 the Alaska Dispatch News (Anchorage, Alaska)

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