Mis­sion Health finds so­lu­tions for bet­ter serv­ing psych pa­tients in the ED

Modern Healthcare - - NEWS - By Harris Meyer

The num­ber of new psy­chi­atric pa­tients ar­riv­ing at Mis­sion Health’s six emer­gency de­part­ments each month shot up 31% be­tween 2014 and 2016, from 419 to 547.

Due to a se­vere shortage of psy­chi­atric in­pa­tient beds in the com­mu­nity, the sys­tem’s flag­ship, Mis­sion Hos­pi­tal in Asheville, N.C., had to hold many of th­ese pa­tients in­side the ED, with the av­er­age num­ber of boarded pa­tients at any one time soar­ing from 15 to 60 dur­ing that two-year pe­riod. One pa­tient who was par­tic­u­larly dif­fi­cult to place lived con­tin­u­ously in the ED for 19 months, un­til he was re­cently dis­charged.

The in­crease in the num­ber of th­ese some­times-dis­rup­tive psy­chi­atric board­ing pa­tients was hurt­ing qual­ity of care for all ED pa­tients and putting both pa­tients and staff at risk of in­jury, Mis­sion Health CEO Dr. Ron­ald Paulus re­cently wrote.

An in­crease in men­tally ill pa­tients ar­riv­ing in hos­pi­tal EDs is a press­ing prob­lem across the coun­try, said Dr. Re­nee Hsia, a pro­fes­sor of emer­gency medicine and health pol­icy at the Univer­sity of Cal­i­for­nia at San Fran­cisco. A study she co-au­thored in Health Af­fairs last year found a 55% jump na­tion­ally in ED vis­its re­lated to men­tal health from 2002 to 2011, from 4.4 mil­lion to 6.8 mil­lion.

Mean­while, the num­ber of in­pa­tient psy­chi­atric beds avail­able na­tion­ally to serve th­ese pa­tients plum­meted nearly 80% from the 1970s to 2010, from about 500,000 to 114,000. In North Carolina, nearly 90% of in­pa­tient beds have closed over the past decade.

The surge in psy­chi­atric pa­tients “is un­safe for ev­ery­one in the ED, and not just phys­i­cally,” Hsia said. She and her col­leagues fre­quently must call po­lice to re­strain vi­o­lent pa­tients be­fore they can chem­i­cally se­date them. Those with con­cur­rent sub­stance abuse is­sues are the most dis­rup­tive.

“Be­cause of the crowded con­di­tions and lim­ited re­sources, even pa­tients with time-sen­si­tive phys­i­cal ill­nesses get poorer care,” she said.

To ad­dress the prob­lem, Mis­sion Hos­pi­tal es­tab­lished four spe­cial hold­ing ar­eas in the ED for psy­chi­atric pa­tients, with the en­tire psy­chi­atric staff round­ing daily on all those pa­tients to pro­vide ac­tive treat­ment, said Dr. Richard Zenn, Mis­sion Hos­pi­tal’s med­i­cal direc­tor for be­hav­ioral health. Two are near the hos­pi­tal’s psy­chi­atric unit, mak­ing it eas­ier to share ex­pert staffers.

Pa­tients with men­tal health is­sues are moved to the be­hav­ioral hold­ing ar­eas—which func­tion like psy­chi­atric units though they aren’t li­censed as such—once they’re cleared on med­i­cal is­sues. “It’s safer and more ap­pro­pri­ate for them, and then they don’t in­ter­fere with the care de­liv­ered to other pa­tients,” Zenn said.

The hos­pi­tal re­cently hired its first full-time emer­gency depart­ment psy­chi­a­trist. Mis­sion Health also cre­ated a be­hav­ioral emer­gency re­sponse team that can be sum­moned by any staffer at any time. It’s get­ting an av­er­age of 30 calls a month.

In ad­di­tion, the sys­tem also started pro­vid­ing telepsy­chi­a­try cov­er­age to eval­u­ate ED pa­tients at its five re­gional hos­pi­tals.

Be­yond that, Mis­sion Hos­pi­tal part­nered with other health­care or­ga­ni­za­tions and the state to open a com­pre­hen­sive men­tal health cen­ter across the street that’s open 24/7 and pro­vides a wide range of cri­sis, out­pa­tient and phar­macy ser­vices.

It’s an ur­gent-care cen­ter for men­tal health, said Sonya Greck, Mis­sion Health’s se­nior vice pres­i­dent in charge

of be­hav­ioral health and safety net ser­vices. “Peo­ple can walk in off the street with no con­di­tions at­tached,” she ex­plained. “They can sit in a liv­ing room and talk with peer spe­cial­ists who have been through this them­selves.”

Cre­at­ing psy­chi­atric hold­ing ar­eas in the ED and hir­ing an emer­gency depart­ment psy­chi­a­trist have led to faster dis­charge of pa­tients with men­tal health is­sues from the ED and im­proved over­all pa­tient through­put, Zenn said. The closely watched “left-without-be­ing-seen” rate for ED pa­tients in March de­clined to 0.27%, from the mid-sin­gle dig­its. That shows wait times and sat­is­fac­tion im­proved for all types of pa­tients.

The open­ing of the out­pa­tient men­tal health cen­ter across the street from Mis­sion Hos­pi­tal has started to bear fruit in re­duc­ing cer­tain types of be­hav­ioral health pa­tients com­ing to the ED, Zenn added.

As­saults on staff mem­bers have fallen, though they still av­er­age about 15 per quar­ter, Paulus wrote.

“All th­ese strate­gies are chip­ping away at the prob­lem,” said Zenn, whose sys­tem is con­sid­er­ing adding new psy­chi­atric beds to its cur­rent sup­ply of 33 adult beds. “But we still have a lot of (psy­chi­atric) pa­tients in the ED.”

A ma­jor prob­lem in North Carolina, and around the coun­try, is that hos­pi­tals don’t get paid for pro­vid­ing be­hav­ioral health­care to pa­tients dur­ing psy­chi­atric board­ing stays, giv­ing them lit­tle in­cen­tive to im­prove care and re­duce th­ese pa­tients' re­liance on the ED. Zenn and his col­leagues are work­ing to en­cour­age the North Carolina Med­i­caid pro­gram to de­velop ser­vice def­i­ni­tions and pay for this care.

In ad­di­tion, since many of th­ese pa­tients are unin­sured, Zenn wants to see North Carolina ex­pand Med­i­caid cov­er­age to low-in­come adults, which the state’s new Demo­cratic gov­er­nor and sev­eral Repub­li­can law­mak­ers have pro­posed. “That would help with ac­cess­ing out­pa­tient ser­vices and pre­vent pa­tients from hav­ing to come to the ED in the first place,” he said.

Still, hos­pi­tals can help solve the psy­chi­atric board­ing prob­lem them­selves, even in a chal­leng­ing re­im­burse­ment en­vi­ron­ment, Hsia said. They could do that by col­lab­o­rat­ing more closely with each other, open­ing more in­pa­tient psy­chi­atric beds, and launch­ing ded­i­cated psy­chi­atric emer­gency ser­vices.

But first they have to rec­og­nize their com­mon in­ter­est in bet­ter serv­ing th­ese pa­tients, rather than re­ceiv­ing and quickly dis­charg­ing them from their EDs, or pass­ing the prob­lem off to safety net hos­pi­tals like hers.

“When hos­pi­tals re­al­ize that not hav­ing th­ese ser­vices can im­pact their bot­tom line be­cause (ED) beds are taken up by non­pay­ing pa­tients, they may un­der­stand it makes sense to fig­ure out a so­lu­tion,” Hsia said. “Be­cause those pa­tients are still com­ing.”

Mis­sion Hos­pi­tal has a spe­cial hold­ing area for psych pa­tients in its emer­gency depart­ment.

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