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. 

A Faster, Kinder Way to Help Patients Through Psychiatric Emergencies

9/14/2016 9:53:11 AM | 2 comments

It looks like there just might be hope for the election after all.
Hackings and taco trucks aside, the campaigning has sparked some very constructive discussion around mental health care policy. It's one of the few issues enjoying bipartisan support this cycle. And with mental illness and substance abuse affecting one in five Americans, it's an area where policymakers can have an enormous impact.
Some promising ideas under discussion include enforcement of parity legislation, which requires insurers to cover mental health and medical care at the same level. There's also talk of mandating public payers like Medicare and Medicaid to reimburse telepsychiatry services delivered in hospitals and primary care offices.
This is great news for hospital EDs, which devote considerable resources to boarding and dispositioning patients who are experiencing a mental health emergency. Researchers at Wake Forest University found that patients with psychiatric emergencies spend three times as long in the ED as patients with physical illnesses and injuries — at an average cost of $2,264 per patient episode.
But if your hospital is struggling with this issue, know that you will likely have options no matter who wins on Election Day. Innovative physician groups are already partnering with hospitals large and small to bring on-demand telepsychiatry consultation into the ED. Such programs can make a real difference to a hospital's bottom line. In today's blog post we'll look at one example: St. Rose Hospital in Hayward, Calif.
The Case for Telepsychiatry
For several years, the St. Rose ED had been battling problems that are all too familiar to hospital administrators.
As a safety net facility, St. Rose receives many patients on involuntary psychiatric holds, known as “5150” holds. Usually this happens when a police officer or mental health worker judges the person to be potentially harmful to themselves or to others. The hold, which lasts 72 hours in California, should ensure these patients get the help they need. But it doesn't always work out that way.
St. Rose is relatively lucky to be located near the John George Psychiatric Hospital, which provides both inpatient and short-term psychiatric emergency services. But demand for its programs often far exceeds capacity. And the referral process for a transfer can at times be cumbersome and lead to delays.
In the past, St. Rose emergency medicine attendings often felt that a patient might have sufficiently improved to no longer require care at John George. They could have helped the system by avoiding a transfer altogether, but the county protocol required that all involuntary patients be sent to the psychiatric facility.
Further, any time a St. Rose patient needed an involuntary psychiatric detention to be initiated, a Hayward Police Department officer had to come on scene to execute the legal hold before the patient could be transferred. Often this meant a substantial wait before an officer became available, during which time the psychiatric patient was not getting help, could not be moved to the psychiatric facility, and was unnecessarily occupying an ED bed, preventing other patients from being evaluated and treated.
And on some occasions, after finally arriving, the officers would even disagree with the emergency physicians’ recommendation altogether and decline to initiate the hold, leaving the doctors stuck in a difficult and increased-liability situation. They felt the patient needed urgent care but would have to release the patient nonetheless because of the police decision.
Not only was this rule troublesome for the emergency department, it also pulled law enforcement resources away from patrolling and emergency response. Clearly, things needed to change.
For help, St. Rose turned to its ED management partner, CEP America.
Support for Mental Health Emergencies
CEP America is a multispecialty independent physician group with expertise in acute psychiatry that has helped many of its hospital partners reduce ED length of stay for mental health emergencies. The group was able to immediately suggest several best practices.
For example, emergency physicians can sometimes expedite disposition by working closely with a psychiatrist. In this scenario, the psychiatrist provides an early diagnosis and initiates therapy while the patient is still in the ED.
Of course, such an arrangement requires a robust call panel or access to an in-house psychiatric department. Yet given the growing shortage of psychiatrists, few hospitals are lucky enough to have these specialists onsite, or even close by.
However, there's another option. Precious psychiatry hours can be spread across multiple hospital sites, perhaps in different cities or even in different states, through the concept of "on-demand telepsychiatry." The concept has worked well in multiple emergency departments across the United States to reduce psychiatric patient boarding, delays, and unnecessary hospitalizations.
And CEP believed that it could also work in Hayward, California.
CEP America proposed to the St. Rose leadership that the hospital might be an ideal site to pilot an on-demand telepsychiatry consultation service. The forward-thinking executives of St. Rose agreed it was worth a shot. So in March 2016, the hospital partnered with CEP to launch the new telepsychiatry service.
Now when a patient presents to the ED with a mental health crisis, the emergency physician can request a telehealth consultation with a board-certified, California-licensed CEP America psychiatrist, who might be many miles away, but can evaluate the ED patient at practically the speed of light. Within an hour, the psychiatrist responds and speaks to the patient via secure two-way video conferencing. After a thorough evaluation, the psychiatrist advises the emergency physician on diagnosis, treatment, and disposition.
With this innovative telepsychiatry support in place, Alameda County’s Board of Supervisors certified the St. Rose ED as the first facility in county history to execute and discontinue involuntary holds via the magic of telepsychiatry. This created a number of benefits for the patient, hospital, and community:
  • Decreased ED length of stay, and much shorter evaluation times for patients. Rather than wait for a transfer to a psychiatric facility to receive a mental health evaluation, select patients can see a psychiatrist promptly while still in the St. Rose ED. If appropriate, the patient can go home or to another non-hospital disposition in far shorter time than was previously the case. It's a win for patients, but also for the ED, which now can more quickly reutilize that bed to help another emergency patient.
  • Less strain on police resources. Officers no longer need to come to the hospital to execute holds. For understaffed police departments, this means more time to focus on duties that keep the community safe.
  • Earlier diagnosis and therapy. The psychiatrist can advise the emergency physician on medications and treatments to ease the patient's distress. In some cases, this resolves the crisis within hours — or even minutes.
  • Less strain on the county psychiatric facility. Thanks to early diagnosis and treatment, some patients can now be discharged from the ED, avoid the county psychiatric facility altogether, and continue treatment as outpatients. This pleases patients, relieves strain on the overtaxed mental health system, and frees up community resources for the patients most in need.
While St. Rose's program is still in its early stages, hospital leaders have been happy with the results so far. "Our goal is to set a gold standard for other emergency departments in California,” said Michael Cobb, Executive Director for the St. Rose Hospital Foundation. “We don’t want patients with mental health problems or their loved ones forced to wait for hours for evaluation or dispositions. We can now provide this important service at our facility, enabling our staff to better treat patients — and perhaps avoid the need for transfers to another facility or costly hospitalizations.”
Strengthening the Emergency Psychiatry Safety Net
Emergency telepsychiatry has worked well at St. Rose and other CEP America emergency departments. Could it be a solution for your hospital?
A key to St. Rose 's success was the selection of experienced physician leadership. In this case, CEP America, their ED management provider, helped the hospital add a collaborative telepsychiatry solution that addressed local needs and requirements. Because of this unique integration, the group was able to run both the ED and psychiatry components for maximum teamwork.
No matter who wins the election in November, it's likely that emergency telepsychiatry could be an option for your hospital and patients. Forward-thinking organizations are already innovating in this area, and they want to work with you.
How does your emergency department handle psychiatric boarding? Comment and tell us about it.

Cyndy Flores
Thanks again for helping CEP take another step forward in finding ways to better deliver the right care to the patients!
9/16/2016 6:44:50 PM

Tamara Longo
CEP continues to expand our expertise in partnership with our facilities to significantly improve the care of patients experiencing psychiatric emergencies. The possibility of available funding to support these efforts is very encouraging!
9/15/2016 7:04:46 AM