EXECUTIVE SUMMARY
A number of communities are turning to community paramedicine programs to help manage the crushing demand on EDs and EMS providers by patients with behavioral health (BH) concerns. In Modesto, CA, a pilot program provides extra training to paramedics to respond to BH-related calls, and a program in Atlanta pairs paramedics with mental health social workers to meet the needs of BH patients, many of whom repeatedly call 911 for help. Both programs curb the need for hospital and ED visits while linking patients with appropriate care more expeditiously. However, a shortage of psychiatric treatment facilities remains a barrier.
- Paramedics in the Modesto, CA, program undergo 140 hours of specialized training in how to handle BH-related 911 calls safely and appropriately.
- Program developers note that most of these patients can be stabilized within 23 hours, nixing the need for a bed in an inpatient psychiatric facility.
- Developers say that the pilot program has saved more than $1 million and significantly reduced the time to treatment for BH patients.
- The Upstream Crisis Intervention program in Atlanta teams a paramedic with a mental health social worker to respond to BH-related calls through a mental health unit that is dispatched through the 911 system.
- The mental health unit teams also check on BH patients when they are not in crisis to make sure they have their medicine and are on track with their plan of care; the teams will intervene if patients need assistance.
As a full-time emergency medicine physician at Kaiser Permanente South Sacramento Medical Center in Sacramento, CA, Kevin Mackey, MD, knows all too well how patients presenting with behavioral health (BH) concerns can fill an ED, resulting in long waits and boarding while staff scramble to find open psychiatric beds in the community.
“The problem strains resources ... and costs a lot of money,” he explains. “In our system, [these BH patients] cost $7,600 per patient, on average.”
To address the problem, Mackey leads an initiative that empowers six specially trained paramedics not only to respond to BH-related calls, but also to resolve many of these calls by either arranging transportation directly to a psychiatric facility or crisis stabilization unit, or by stabilizing patients on the spot and establishing appropriate follow-up care.
The approach, which has been in effect since Nov. 25, 2015, has reduced the amount of time it takes to connect these BH patients to appropriate care drastically, and preliminary figures suggest it has saved more than $1 million, according to Mackey. Although there are still kinks to work out, such as a way to achieve sustained funding for the approach and find an answer to the shortage of psychiatric facilities in the region, Mackey sees the approach as one potential solution to a problem that plagues too many hospitals.
“Many, many EDs struggle with this,” he stresses.
Equip Paramedics with Training
Mackey, who also serves as medical director of Modesto, CA-based Mountain Valley EMS, needed a waiver from the state EMS authority to launch the program because current regulations do not allow paramedics to transport patients anywhere other than the ED.
“There are currently 12 approved projects in California looking at various aspects of mobile integrated health practice, or MIHP,” he explains. “Our project is looking at the strain on the ED from BH patients.”
The six paramedics involved in the program have undergone 140 hours of additional training.
“They trained alongside law enforcement in something called crisis intervention training [CIT], they spent time with BH specialists and with public health, and then they went through a program run by UCLA,” Mackey notes.
Part of this training goes toward empowering the paramedics to conduct a mental health screen. When they respond to BH patient calls, paramedics perform both a mental health screen and a patient safety screen, Mackey says.
Currently, there are three ways these specially trained paramedics can be engaged. First, when someone calls 911 and an ambulance is sent to the scene, if the EMS team determines the patient has no medical issues and that the problem is purely psychiatric, the team then can trigger a response of the community paramedicine team.
“That ambulance engages the community paramedic through the 911 system, and then the community paramedic comes to the patient’s side and does an assessment,” Mackey says. “The community paramedics work as a single resource. They travel in SUVs that are equipped as paramedic units, but they do not transport [patients] at all.”
The second way the community paramedics can be engaged is through law enforcement.
“The police department has been trained about our program and when patients are appropriate,” Mackey says, noting patients must be fairly cooperative. “They can be acutely psychotic, but they can’t be psychotic and extremely aggressive, requiring restraint.”
The third way community paramedics can be called to the scene is when a patient walks into a psychiatric hospital.
“Most psychiatric hospitals in the country require patients to have medical clearance, and currently, our psychiatric hospital doesn’t have the ability to do that, so the county has to pay for an ambulance to transport that patient to an ED to, again, take up a bed and resources, and then the county pays to have the patient transported back to the psychiatric center,” Mackey notes. “Instead of doing all that, the community paramedic will go to the patient’s side in the lobby of the BH hospital and do the medical clearance right there.”
Link BH Patients to Care
Now that the BH-focused community paramedics have responded to nearly 700 patient calls, program administrators have a good sense of what the mental health needs are in the region.
“We have noticed that the vast majority of our patients are in their 30s, and the vast majority are male and Caucasian,” Mackey explains. “We did not expect that because we have a large Hispanic population here.”
The primary complaint typically is depression, suicidal ideation, or psychosis, Mackey notes. Specifically, many of these patients have a history of schizophrenia and they are off their medications, and an even larger percentage have taken methamphetamines and are acutely psychotic, he says.
When community paramedics determine that a patient needs placement in a psychiatric facility, they will call ahead and make sure there is a bed available prior to transport. When there is availability, the patient typically is transferred within 90 minutes. Unfortunately, roughly one-third of the time, there is no bed available. Mackey notes that although the number of psychiatric beds has decreased by about 25% over the past decade, the population and the need for these beds has continued to grow.
“There is a gap now of 44.9% between availability and need,” he says. “That is the number one reason why we can’t, on occasion, take patients directly to psychiatric facilities.”
When no psychiatric bed is available, patients are transported to the ED, but Mackey suggests that a solution to this problem is not necessarily the construction of more psychiatric hospitals.
“Most of these patients don’t require a 24-hour hospitalization; most can be stabilized in 23 hours,” he says. “They just need to be put back on their medicines, they need to be given resources, and they need to be shown the way. That is for the vast majority. There are a few patients that do require hospitalization.”
Demonstrate Savings, Benefits
As far as next steps, Mackey intends to publish the results of the program from a safety aspect.
“When I started on this project, I was told by a lot of psychiatrists that there is no way that a paramedic can safely do this, so throughout this entire project my personal goal was safety; I wanted to prove that it could be done safely,” he says. “I have followed all of my patients all the way through the process, and we have had zero patients fall out or bounce back because the paramedics failed to recognize a medical issue.”
Mackey also intends to thoroughly analyze and publish the results of the program from an economic standpoint to illustrate how much money it can save the healthcare system.
“When you can show how money is saved, I think you can get folks to open up their pocketbooks a little bit instead of coming in with your hat in your hand and saying, ‘please donate,’” he says.
The program already has elicited such strong support from law enforcement that Mackey believes there could be some financial support for the program from that sector.
“In the past, officers would go to one of these calls, then they would put the patient in the back of one of their cars, and they would transport the patient to the ED,” he says. “Then they would stand in the hall of the ED waiting for a bed and a security officer, fill out the 5150 [for an involuntary psychiatric hold], and eventually return to service.”
The amount of law enforcement service time that the program has saved is astronomical, Mackey notes, and he intends to tally these results, too.
“We expect those numbers to be really remarkable,” he says, noting that these benefits are on top of what the program delivers in terms of efficiency and care quality. “My whole interest in this is because of what a huge win it is for the healthcare system and also for patients.”
Add Mental Health Expertise
The Grady Health System (GHS) in Atlanta has been leveraging community paramedics to help manage BH-related 911 calls for five years through a program called Upstream Crisis Intervention. However, in this approach, paramedics work alongside mental health social workers when responding to calls. The method has worked so well that what originally began as a three-week pilot program never ceased, notes Michael Colman, MPA, NR-P, the vice president of EMS Advanced Practice at GHS. The program originally was conceived because of the high number of patients with BH needs who repeatedly call 911.
“Every month, there are probably 75 to 100 patients who call 911 more than five times a month,” Colman says, explaining this was an issue because paramedics generally do not have the expertise to manage BH patients.
“We spend a lot of time learning about cardiac arrest management, gunshot wounds, trauma, and things like that,” Colman notes. However, he observes that responding to a call involving someone who is experiencing a mental health crisis requires a different skill set. “When we would get [to the scene], it was really hard for us to figure out how to best interact with the patient without escalating the situation.”
In many of these cases, law enforcement was engaged, and the patient might be subdued or restrained. Such situations might become dangerous and unpredictable, often leaving prehospital providers fearing for their safety and unclear on how to proceed.
“We were just looking for a better way to manage our mental health calls because we knew they weren’t going to stop coming,” Colman adds.
In the initial stages of the Upstream Crisis Intervention program, Grady EMS dispatched the paramedic/social worker teams, along with a psychiatrist.
“We really wanted to make sure this idea was safe, that it was going to work, and that it made sense,” Colman says. “From a medical standpoint, everyone felt it was great, and we are also now really comfortable with the process.” (See also in this issue: “Prevent Mental Health Problems from Escalating into Crises.")
Integrate Resources
Roughly 7% of the 911 calls into Grady’s EMS system involve a mental health-related complaint, but these do not necessarily represent an immediate threat to a person’s life. Many of these patients are depressed or anxious, or they may just want to talk to someone. “They don’t necessarily want to go through the whole ED process,” Colman says.
Consequently, one of the first steps that the Upstream Crisis Intervention program took to address these calls was to reach out to the Georgia Crisis and Access Line (GCAL), a program that can fulfill the immediate needs for many of these patients by providing them with a mental health provider to talk to and connect them with appropriate follow-up appointments.
The 911 dispatchers will triage calls over to GCAL in cases in which the approach is deemed most appropriate, negating the need for an ambulance or transport to the ED.
“The person’s call is transferred, [GCAL staff will] talk to them, they set up a safety plan, and get an appointment with one of the mental health facilities in their area,” Colman says. “Sometimes, the issue can be solved over the phone.”
If GCAL staff members express any concerns, they can dispatch their own internal mobile crisis program, or they can call Grady EMS back, Colman explains.
The Grady EMS system features a sophisticated, computerized emergency dispatch system that will assign a code automatically based on the answers to questions the dispatcher asks. There are roughly 1,500 codes that can be assigned according to the system’s underlying algorithms, and these guide the dispatchers’ actions, Colman explains.
For more serious mental health-related calls, these codes typically will prompt 911 dispatchers to deploy one of the mental health units manned by a paramedic and a social worker. These calls involve issues such as suicide, depression, bipolar disorder, or schizophrenia, according to Colman.
In these cases, the paramedic will evaluate the patient first to take vital signs and identify any medical issues of concern. “Once we get the patient checked out and he is [medically] OK, then we have the mental health social worker start talking to him,” Colman says. “The social worker may do a safety plan, work through whatever their condition is ... and make the patient a next-day appointment to see a mental health provider, or we can transport the patient, if needed, to the ED or to an inpatient mental health facility.”
However, there are times when the mental health unit team determines that a patient requires more intervention.
“If the patient is violent or needs some medication to be transported, the paramedic will administer the medicine and then wait for an ambulance because we do not transfer people that we have to medicate because it is not safe to do so,” Colman notes.
It should be noted that in cases in which ambulances or vehicles are owned and operated by the hospital, the Emergency Medical Treatment and Labor Act (EMTALA) may apply to interactions with the target individuals. For more information on this point, please see “An Ambulance Owned by a Hospital Must Also Be Operated by a Hospital to Trigger EMTALA Obligations,” published in the May 2013 issue of ED Legal Letter (http://bit.ly/2iuAYtE).
Begin Processing in the Field
In 2015, mental health units responded to nearly 1,600 calls, and in the vast majority of these cases, the paramedic/social worker team was able to manage the situation without transporting the patient to the ED. In most of these cases, the patients received follow-up appointments with mental health providers, enabling the health system to preserve resources while also quickly connecting patients with needed care, Colman explains.
The mental health unit teams determine a patient must be transported to the hospital about 400 times a year, but even in these cases, the prehospital provider team works to minimize delays. One of the mental health unit team members will ride with the patient and make sure he or she is monitored and comfortable, Colman says.
“Once we get to the hospital, it speeds the process because the paramedic speaks with the nurse, reports on the patient’s vital signs, explains what has already been done for the patient, and passes on the patient’s history,” he says. “Then, the mental health social worker from the unit will report his or her findings to the psychiatrist or a mental health professional who is on staff in the ED.”
By this point, the mental health social worker from the team has been with the patient for at least 45 minutes and may have even seen this patient before, Colman offers.
“This can potentially shave a couple of hours off the patient’s stay in the ED,” he says. “The patient can already be on a path to either getting admitted or really just being discharged [if his needs can be managed in the ED].”
About 70 times a year, the mental health unit determines that a patient must be transported to an inpatient mental health facility. It is a process that has become increasingly difficult, as such facilities often are full, and the state has moved to a single point of entry for patients who need a bed in one of these facilities, according to Colman. However, the mental health unit teams can initiate the admissions process.
“We start the process in the field so that when the patient gets to the ED, usually at Grady Memorial Hospital, we can say that ... the patient is already in line for a bed,” Colman says. “This shortens the amount of time that the patient is going to spend at Grady waiting for a bed to become available.”
Now that the program has been in operation for five years, the mental health unit teams have become familiar with many of the callers, and these teams often can anticipate their needs, Colman notes.
“It is much less expensive for this unit to respond rather than sending an ambulance since the paramedic/social worker team is so familiar with the patients,” he says. Often, it is just a matter of making sure a patient is taking his or her medicine as directed and that he or she is appropriately housed and nourished, Colman adds.
“That task becomes more difficult for an ambulance because on any given day, we could have 25 or 30 ambulances in the field, and the people in those ambulances don’t encounter these patients frequently, so they may be unsure of whether the patient is in extremis or is [acting in accordance with] his or her normal mental health condition,” Colman explains. “A lot of times [in the past], these patients would be unnecessarily transferred to the hospital.”
Although Grady has not specifically tallied financial results, it’s clear the program delivers dividends.
“We know that about 65% of the time, when [the mental health unit teams] get on the scene, the patient doesn’t go to the ED, which is nice, and about 92% of the time the patients don’t get an ambulance,” Colman reports. “Before [the program was implemented], these patients got an ambulance 100% of the time, and 80% of the time they went to the hospital.”
In many of these BH-related calls, all the patients really need is an appointment with a mental health provider, Colman notes. Rather than taking them to the ED, the mental health unit teams can handle that task in the field.
“We have found a better way to get this same result,” he says.
SOURCES
- Michael Colman, MPA, NR-P, Vice President, EMS Mobile Advanced Practice, Grady Health System, Atlanta. Email: [email protected].
- Kevin Mackey, MD, Emergency Medicine Physician, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA; Medical Director, Mountain Valley EMS, Modesto, CA. Email: [email protected].
While a dearth of psychiatric beds remains an obstacle, EMS-driven interventions are making a dent in hospital utilization, ED crowding.
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