Solutions for the ED: Effectively serving patients with mental illness, while alleviating pressures on providers

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Approximately 1 in 5 Americans suffer from a mental illness,1 and too many lack adequate, timely care for their disorder.2

Appropriately serving the vast number of people in the United States suffering from mental health disorders can be challenging in today’s health care environment. The trend of deinstitutionalization—the closing of public psychiatric hospitals that had been part of the nation’s safety net as far back as the 1830s—has led to a major shortage of available psychiatric beds, and the hospitals left to pick up the slack often lack in-house psychiatric services.

Mental illness is currently the third most common cause for hospitalization in the United States for youth and adults under 45.3 That figure has an even more alarming context: nearly half of polled ED physicians reported that one or more psychiatric patients wait in their ED each day for an in-patient bed to open up.4 None of this will be news to emergency physicians or hospitalists who admit such patients while trying to help their overextended emergency departments.

Patients with psychiatric disorders deserve better. To fully accommodate their needs, however, will require changes to legislation, resource allocation, reimbursement, and professional training. Absent these broader changes, front-line physicians can use available resources and new technologies to close the current gaps in care. Together, hospitalists and EDs can find better ways to serve this patient population, while also alleviating pressures along the course.

Reinforcing patient-centered partnerships
Hospitalists and ED physicians alike face the problem of limited resources for patients with mental health disorders. These resources include space, beds, access to psychiatric services, and time. Too often these limitations breed a feeling of powerlessness, which can in turn lead to frustration or even infighting. Front-line physicians can reestablish a patient-focused partnership by thinking of the resources of the ED and the hospital as one complete set of resources—one pool from which they both can draw to provide the best care for the patient. For instance, if the ED needs to admit a patient who has come in because of a psychiatric illness, they can request a sitter for the floor so the hospitalist doesn’t have to put the patient in an ICU bed. In this one scenario at least, the patient gets the attention that he or she needs, while the hospitalist can reserve 1-to-1 care and valuable ICU beds for those with acute medical needs.

Technological solution: Telemedicine
Much of the friction between ED physicians and hospitalists is caused by the same thing that frustrates mental health activists: the time it takes to get behavioral health patients the attention they need. Because so many of these delays are due to issues of staffing availability and cost, hospitals and health systems are increasingly exploring technological alternatives to in-person visits. These include forms of mental health care that can be conducted remotely, usually via a secure audio or video platform. Such programs can be served by psychiatrists, psychologists, social workers, counselors, therapists, or a combination thereof.

The promise of telemedicine is that it can connect patients to the appropriate clinical care, education, monitoring, and consultations anytime and anywhere. In practice, even being able to perform a psychiatric consult an hour or two earlier in the patient’s clinical experience can help immensely. (In fact, as University of Pennsylvania researchers found, mental health patients waited on average almost two hours longer in the ED than those needing general medical care.5) A videoconference can allow the consulting psychiatrist to observe the patient and interact with them—and, in some cases, write a prescription on the spot.

Telemedicine applications for management of psychiatric health issues such as stress and depression may seem less immediately important for alleviating pressure on the ED. But they are actually part of a larger net of resources that can help keep patients from reaching the point where they need acute care.

Advocating effectively for more resources
Who are the people in the best position to change this situation? The healthcare professionals who, on a daily basis, see that these patients aren’t getting the care they need.

ED physicians, hospitalists, and hospital leaders should all be working together to examine policies and procedures governing psychiatric care, including a systemic standard for coordinating psychiatric care. Such a standard would formalize the process for determining to which facilities or other organizations mental health patients will be referred or transferred.

Any plan that is brought to hospital leadership must of course include the business case for change as well as an explanation of how the change will improve the quality of care. For instance, ED leaders can quantify and document the excessive wait times mental health patients experience—but they can also work with hospitalists to identify how those delays increase the length of stay (LOS) or risk for readmission within 30 days (costly metrics, as any hospital executive knows). Another approach would generate the ROI for additional telemedicine resources, estimating the percentage of patients who come into the ED with mental issues and computing the LOS (or other revenue-impacting measures) for those patients. That figure could be compared to the cost of adding capacity via telemedicine.

Collaboration beyond the walls of the hospital
To make real change for the more than 40 million Americans suffering from mental disorders, and particularly for those patients who rely on the emergency department for care, physician leaders should seek out solutions beyond their organization.

Collaboration with interested experts is an excellent place to start. Physician leaders can contact the facilities where psychiatric patients are currently being transferred to learn what additional solutions they might be able to bring to the table. Are other referring organizations doing something innovative? What best practices or innovations might those services advise for the ED or the hospital?

The same old approach isn’t serving patients or providers. Taking advantage of technology, expertise, collegiality, and collaboration is the only way forward.

About Schumacher Clinical Partners: Founded and driven by strong physician leaders, Schumacher Clinical Partners is dedicated to helping hospitals and providers deliver the best in patient care. As one of the nation’s largest and fastest growing healthcare resources, SCP partners with more than 7,200 providers, serving 8 million patients annually with innovative, patient-centered solutions, including emergency medicine, hospital medicine, wellness programs, and consulting services.

1 https://www.npr.org/sections/health-shots/2016/10/17/498270772/how-gaps-in-mental-health-care-play-out-in-emergency-rooms
2 https://www.nami.org/Learn-More/Mental-Health-By-the-Numbers
3 https://www.nami.org/Learn-More/Mental-Health-By-the-Numbers.
4 http://newsroom.acep.org/2016-10-17-Waits-for-Care-and-Hospital-Beds-Growing-Dramatically-for-Psychiatric-Emergency-Patients.
5 https://www.psychiatry.org/news-room/apa-blogs/apa-blog/2016/11/emergency-room-visits-for-mental-health-conditions-expect-long-waits.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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