Psych pa­tients strain­ing ERS

Pro­grams aim to re­di­rect psy­chi­atric pa­tients

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Bor­der­line per­son­al­ity dis­or­der. Schizophre­nia. Psy­chotic ten­den­cies. Sui­ci­dal be­hav­iors. Typ­i­cally found in the caseload of an in­pa­tient psy­chi­atric fa­cil­ity, these con­di­tions have be­come preva­lent in an­other area of the U.S. health­care sys­tem: the acute-care hospi­tal emer­gency depart­ment.

In 2006, an In­sti­tute of Medicine re­port con­cluded hospi­tal emer­gency rooms are over­whelmed, cit­ing in­creases in lengths of stay for pa­tients seek­ing care, crowd­ing of ex­ist­ing ER space and board­ing of pa­tients who need an in­pa­tient bed as the rea­sons.

And a re­cent study pub­lished on­line in the An­nals of Emer­gency Medicine shows that psy­chi­atric pa­tients spent more than 11 hours in the ER, on av­er­age, when they sought care. Ac­cord­ing to the re­cent find­ings, the need for hos­pi­tal­iza­tion, use of re­straints and com­plet­ing di­ag­nos­tic imag­ing led to more time af­ter a pa­tient was as­sessed, while the pres­ence of al­co­hol on tox­i­col­ogy screen­ing caused de­lays ear­lier in ER stay.

“Ba­si­cally, the ER has gone from an emer­gency room to a place where all of so­ci­ety’s prob­lems show up,” says Dr. Ni­cholas Vasquez, an emer­gency ser­vices physi­cian at St. Joseph’s Hospi­tal and Med­i­cal Cen­ter in Phoenix, who did not speak on be­half of the hospi­tal. “And one of those is men­tal health is­sues.”

A noisy, chaotic place isn’t the ap­pro­pri­ate set­ting for pa­tients who re­quire sta­bil­ity and quiet, says Vasquez, past pres­i­dent of the Ari­zona Col­lege of Emer­gency Physi­cians. As he ex­plains, the 60-bed emer­gency depart­ment where he works ex­pands and con­tracts through­out the day and in­cludes an av­er­age of three to four psy­chi­atric pa­tients daily.

Vasquez says pa­tients “run the gamut from base­line schizophre­nia and home­less, or you have worse com­bi­na­tions—re­nal fail­ure (pa­tient) who needs dial­y­sis and is schiz­o­phrenic,” he says. “They are the ones who die early; you can’t pre­sume they will take care of them­selves. You can’t pre­sume they will take their med­i­ca­tion.”

Take, for in­stance, a re­cent pa­tient Vasquez treated who showed up in the ER cov­ered in a black sub­stance that Vasquez iden­ti­fied as tire cleaner. “He was telling me there were three Earths, he was rap­ping, and he was on meth,” Vasquez says. “We did what we al­ways do: call the se­cu­rity guards, put him in leather straps, gave him chem­i­cal se­da­tion, cleaned him up and called the psy­chi­a­trist. For the nonag­i­tated, we’ll put them in a bed, put them in a gown, and have some­one sit and watch them so they don’t try any­thing.”

The cause of ad­di­tional psych pa­tients in emer­gency de­part­ments is mul­ti­fac­eted. To be­gin, the Na­tional As­so­ci­a­tion of State Men­tal Health Pro­gram Di­rec­tors re­ports that nearly 4,000 state psy­chi­atric hospi­tal beds have been elim­i­nated since 2010, a year when 46 states faced bud­get short­falls.

“What we’re see­ing is most state men­tal health hos­pi­tals op­er­at­ing are fo­cused on the foren­sic pa­tients and long-term-care pa­tients, not the acute-care pa­tients,” says Mark Co­vall, pres­i­dent and CEO of the Na­tional As­so­ci­a­tion of Psy­chi­atric Health Sys­tems, which rep­re­sents be­hav­ioral health­care providers that own or man­age more than 700 psy­chi­atric hos­pi­tals, gen­eral hospi­tal psy­chi­atric and ad­dic­tion treat­ment units and be­hav­ioral health­care di­vi­sions, res­i­den­tial treat­ment fa­cil­i­ties, youth ser­vices or­ga­ni­za­tions and out­pa­tient net­works.

Foren­sic pa­tients are those who have some le­gal pro­ceed­ing that keeps them in a hospi­tal rather than jail.

“So that sys­tem has gone away, and they are seek­ing care in the com­mu­nity,” Co­vall says. “And be­cause there are not as many re­sources for them, they end up go­ing to the only place that does have 24/7 care, and that’s the emer­gency depart­ment.”

Of­ten, psy­chi­atric pa­tients are home­less or live in un­sta­ble hous­ing sit­u­a­tions and re­turn re­peat­edly to the ER. In the past, these pa­tients would be sent to the state men­tal health sys­tem, but that doesn’t hap­pen as much any­more, as states face bud­get prob­lems and tighten their be­hav­ioral health re­sources. The public health sys­tem has con­tracted more quickly in the past decade and has been hit es­pe­cially hard in the past five years, Co­vall says.

“In health­care, we’re try­ing to shift re­sources,” he says. “In the men­tal health arena, we had the public men­tal health sys­tem and the pri­vate sys­tem—they used to op­er­ate in­di­vid­u­ally,” he adds. “But as the public sys­tem con­tracted, it put more pres­sure on the pri­vate sys­tem, which shows it­self in the ED. The EDS are the safety net. That’s where it’s vis­i­ble—that’s where you can see what’s hap­pen­ing.”

This is why Co­vall says there is a great need for bet­ter co­or­di­na­tion be­tween the public and pri­vate men­tal health­care sys­tems, and also an ex­pan­sion of com­mu­nity-based ser­vices.

“In do­ing so, it’s not nec­es­sar­ily more money, but run­ning them more ef­fi­ciently,” he says.

Psy­chi­atric pa­tients in hospi­tal ERS have been a “chronic prob­lem” in the state of Maine for the past 10 to 12 years, says Den­nis King, CEO of Spring Har­bor Hospi­tal, an 88-bed not-for­profit psy­chi­atric fa­cil­ity in West­brook. King also serves as pres­i­dent and CEO of Maine

Men­tal Health Part­ners, a not-for-profit or­ga­ni­za­tion fo­cused on build­ing an in­te­grated sys­tem for men­tal health providers across 11 coun­ties in the state.

King says about 5% of Maine care (the state Med­i­caid pro­gram) par­tic­i­pants ac­count for about 55% of the costs in hospi­tal ERS. And at Spring Har­bor, about 25 pa­tients have more than five stays a year in the fa­cil­ity and are among the high­est users of hospi­tal’s emer­gency ser­vices.

To ad­dress this is­sue, Spring Har­bor joined with Maine’s Health and Hu­man Ser­vices Depart­ment and Shalom House—a Port­land­based or­ga­ni­za­tion that pro­vides com­mu­ni­ty­based ser­vices for adults with men­tal ill­nesses— to es­tab­lish the As­sertive Com­mu­nity Treat­ment In­te­grat­ing Out­pa­tient Net­works, or AC­TION pro­gram, which be­gan in 2007.

Funded by Maine’s HHS depart­ment and Maine care, the pro­gram re­lies on Spring Har­bor for the ther­a­pists, psy­chi­a­trists and the nurs­ing func­tion for a spe­cific pop­u­la­tion and on Shalom House for the res­i­den­tial needs.

“It’s a com­bined treat­ment team so res­i­den­tial staff know the ther­a­peu­tic goals for each client,” says Ed Blan­chard, clin­i­cal di­rec­tor at Shalom House. “Even though it’s two or­ga­ni­za­tions, it’s one clin­i­cal team,” he says, adding that the or­ga­niz­ers wanted to de­velop a pro­gram that would help pa­tients gain skills and also avoid ER vis­its and hos­pi­tal­iza­tions.

Lo­cal hos­pi­tals are aware of pa­tients in the AC­TION pro­gram—which tops out at 25 in­di­vid­u­als—and they re­fer pa­tients in the ER ei­ther to be hos­pi­tal­ized at Spring Har­bor, or to Shalom House, which pro­vides ei­ther a group home or in­de­pen­dent liv­ing (with ac­cess to staff and medicine). The pro­gram re­lies on an As­sertive Com­mu­nity Treat­ment, or ACT, team, which in­cludes a psy­chi­a­trist, nurses and case man­agers.

Dr. James Wo­lak is di­rec­tor of psy­chi­atric emer­gency ser­vices at Maine Med­i­cal Cen­ter in Port­land, the largest hospi­tal in the state. The hospi­tal and Maine Men­tal Health Part­ners are part of the Maine health sys­tem. Three years ago, the hospi­tal ren­o­vated its emer­gency depart­ment, which has a six-room psy­chi­atric unit. Maine Med­i­cal has about 5,000 en­coun­ters with psy­chi­atric pa­tients an­nu­ally, of whom about 27% are ad­mit­ted to a psy­chi­atric hospi­tal.

Wo­lak says the hospi­tal used to ad­mit more pa­tients to psy­chi­atric fa­cil­i­ties, but has been able to de­crease the num­ber partly through more so­phis­ti­cated as­sess­ments. Mean­while, pa­tients wait­ing to be ad­mit­ted to an in­pa­tient psy­chi­atric hospi­tal of­ten have to wait longer in the emer­gency depart­ment—some­times as long as 24 hours—un­til a bed be­comes avail­able.

“An­other rea­son why we’ve been able to de­crease our ad­mis­sion rate is that we have these re­sources in the com­mu­nity that we can use,” Wo­lak says, adding that Maine Med­i­cal has had a work­ing re­la­tion­ship with the AC­TION pro­gram from the start. He says the re­la­tion­ship goes be­yond a re­fer­ral and a dis­charge be­cause it in­volves a co­or­di­nated treat­ment plan. Rep­re­sen­ta­tives from the hospi­tal have reg­u­lar meet­ings with AC­TION team mem­bers, which al­lows them to pro­vide bet­ter treat­ment for the pa­tients.

“It was in­no­va­tive think­ing, reach­ing out across sys­tems and get­ting dif­fer­ent play­ers in the over­all men­tal health­care de­liv­ery sys­tem to com­mu­ni­cate and work with each other, rather than op­er­ate in their own lit­tle bub­bles,” he says. “And to also ap­proach pa­tient care—to view the over­all pa­tient-care plan for each pa­tient, rather than deal­ing with the here and now—which is the ED men­tal­ity.”

Maria Long, right, a li­censed clin­i­cal so­cial worker on staff with Maine’s AC­TION pro­gram, talks with a pa­tient dur­ing a re­cent coun­sel­ing ses­sion. The col­lab­o­ra­tive ini­tia­tive launched in 2007.

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