Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions.

Dedicated Psychiatric Emergency Services Reduce the Need for Inpatient Hospitalizations

4/30/2015 3:12:11 PM | 4 comments

The eastern Texas town of Lufkin is located over 50 miles from the nearest FedEx delivery point. In the past, area residents in psychiatric crisis endured long waits in the emergency department (ED), hospital or even jail to access specialized behavioral healthcare — often at facilities far from home. But that's all changing, thanks to an innovative new delivery model.
The Burke Center Mental Health Emergency Center in Lufkin is the world's first outpatient psychiatric emergency service with zero psychiatrists on staff. Instead, care is supervised by telepsychiatrists and delivered onsite by a multidisciplinary team of counselors and nurses. The center offers a comprehensive range of services, including an extended observation unit, a crisis residential unit and a mobile crisis response team.
The results have been striking. State hospital bed utilization in the 12 participating counties has decreased by 32 percent. Patients have been overwhelmingly satisfied with the care provided. In 2011, the Burke Center was honored with an American Psychiatric Association Gold Award for innovation and achievement.

Time for a Paradigm Shift?

The experiences of the Burke Center and similar programs across the country suggest that acute psychiatric crises can often be resolved in the outpatient setting. Yet at EDs across the country, patients wait an average of 8 to 34 hours for an inpatient bed at a behavioral health facility.
In addition to costing $2,264 on average, the practice of boarding psychiatric patients in the ED contributes to crowding, which decreases all patients' safety and satisfaction. In EDs without adequate psychiatric coverage, these patients may receive little immediate treatment, and the noisy, chaotic environment may exacerbate their fear and agitation.
So why do we continue boarding these vulnerable patients? One reason is the assumption that most people in psychiatric crisis need inpatient care. Patients presenting to the ED with a psychiatric condition are 2.5 times more likely to be admitted than those with only a medical diagnosis.
Another factor is that many behavioral health patients arrive in the ED under an involuntary hold, meaning a designated professional has judged them to be dangerous or gravely disabled. Some jurisdictions allow emergency physicians to lift involuntary holds, but even in these locations, there are substantial liability risks associated with this practice that undercut the reasoning behind the hold — namely, to get the patient a comprehensive psychiatric evaluation. Where there is no reasonable process for lifting holds, hospitals may have no choice but to admit all involuntary patients for disposition. (This would be analogous to admitting all chest pain patients rather than the 10 percent who actually need inpatient care.)
In my experience, this emphasis on inpatient care is misguided for several reasons:
  • With proper care, many psychiatric emergencies resolve within 24 hours, allowing patients to safely continue treatment in the community.
  • Surveys show that both ED directors and consumers strongly support the development of specialized psychiatric emergency services.
  • The number of inpatient psychiatric beds has been shrinking steadily since the 1950s, and there's no indication that this trend will reverse in the future.
Hospitals and communities should therefore consider investing in alternative treatment designs that emphasize prompt intervention and stabilization in the outpatient setting.

The Alameda Model

For the past 19 years, I've been fortunate to serve as Chief of Psychiatric Emergency Services at John George Psychiatric Hospital. We're a standalone behavioral health facility within the Alameda Health System, the safety-net healthcare provider for the East Bay region. Over the years, we've developed a regional model for psychiatric emergency care that has become a blueprint for programs around the country. We call it the Alameda Model.
Our psychiatric emergency service (PES) is an EMTALA-compliant, psychiatric-patient-only ED on the John George campus, which works with 11 area medical EDs to provide intensive treatment with the goal of rapid stabilization. The department is staffed around the clock by psychiatrists and nurses and serves all medically stable patients regardless of ability to pay. Services are provided on an outpatient basis. Maximum length of stay in the PES is 24 hours, which is fully covered under the "crisis stabilization" provision of California's Medicaid program.
Patients arrive at the PES in one of three ways:
  • Directly by ambulance. When a police officer places an involuntary psychiatric hold, they call emergency medical services (EMS). The ambulance team responds and performs a field screening to determine whether the patient needs medical attention. About 60 percent of patients are brought directly to the PES. Transport by ambulance is more appropriate for patients (as EMTALA considers psychiatric emergencies to be medical emergencies) and also frees up law enforcement resources for community policing.
  • Transfer from a medical ED. Patients in psychiatric crisis can be transferred to the PES as soon as they are medically stable. There is no need to wait for an inpatient bed. The process is analogous to transferring an ED patient to a higher level of care such as a regional trauma center.
  • Self-referrals. Ambulatory patients can present directly to the PES for care.
The PES approach has many benefits. About 75 percent of our patients are discharged within 24 hours, and this figure is common for PES programs around the nation. This demonstrates that even patients in crisis can be stabilized quickly in the less-restrictive outpatient setting. The PES model reduces the need for hospitalization, freeing up scarce inpatient beds for those who are truly in need.
Hospitals are also reaping the benefits. Psychiatric boarding at Alameda County EDs has all but disappeared. Once medically cleared, the average behavioral health patient waits less than two hours for transfer to the PES. Hospitals no longer need to provide around-the-clock psychiatric coverage and can often scale back their case management services.

Other PES Programs

There are currently a few hundred PES programs operating across the county. They are typically run by local government, a single hospital or health system or a regional consortium of stakeholders. An example of the latter is under development in Portland and is a joint venture among four hospitals, police and fire departments, and the city and county governments.
The PES model is highly adaptable and can be tailored to stakeholders' needs, local laws and the community's philosophy of care. That being said, it doesn't make sense for every health system or community. In order to justify its costs, the program needs to treat about 3,000 psychiatric emergencies a year.
In addition, not all payers reimburse for crisis stabilization. (On a hopeful note, I am part of a group of physicians that is advocating for this coverage on a national level, so this could change over the next couple years.)

Leading Change

So how can hospitals interested in redesigning emergency psychiatric care get started?
I think a good first step is to bring together all of the stakeholders, including providers, hospital administrators and representatives from community mental health organizations. Let each participant share how they see the problem and what, in their opinion, needs to change.
Start developing a consensus around next steps. Bear in mind that a PES is just one option. Others include telepsychiatry, developing a crisis stabilization unit or advocating for policy change around involuntary holds. Individual EDs can often accomplish a great deal by creating more welcoming, therapeutic environments for patients.
Finally, as you work to gain buy-in, emphasize the big picture. While change is never easy, innovative delivery models like the PES and telepsychiatry complement the goals of healthcare reform. All forms of healthcare delivery are currently shifting toward outpatient settings, and emergency psychiatry is no different. Our efforts will benefit not only our behavioral health patients but also the communities that rely on our EDs for lifesaving care.

[Image credit: "Clinic Counseling Session" by hellocoolworld licensed under CC BY 2.0]

Ryan Petersen
Great article and a unique solution to a growing problem. I would be very interested if you have any protocols that you use to medically clear patients before transfer to PES.
Thanks in advance.
5/4/2015 11:08:37 AM

Tom Sugarman
Thanks Scott.

The work you are doing to help mental health patients get the care they need in a timely fashion, while decreasing the time they spend on unjustified holds is great. Our medical system needs to improve to better serve these marginalized patients and you are helping to lead that improvement.
5/1/2015 12:17:48 PM

Jon Brummond
Yes it is time for a paradigm shift. Great article.
Thanks for contributing!
5/1/2015 10:23:01 AM

Great article Dr Zeller! The MHEC and PES models are truly innovative solutions for our patients. Thanks for your hard work and advocacy.
4/30/2015 11:39:48 PM