Embedded crisis workers help decompress ED
Look to other health systems for solutions
With diminished funding for mental health (MH) services in Pennsylvania, patients with MH or substance use concerns have been presenting to area EDs, explains Michael Turturro, MD, FACEP, the chief of emergency services at the University of Pittsburgh Medical Center (UPMC)-Mercy. "Over a two-to-three year period, while our overall volume in the ED went up by about 20% to 25%, the volume of patients presenting for MH and/or addiction issues requiring inpatient care went up by more than 300%."
As budget cuts forced the closing of area facilities that had been providing inpatient and outpatient care to MH patients, the situation at UPMC-Mercy reached a crisis stage by the summer of 2012. "Our ED became overburdened and overcrowded, with behavioral health and detoxification patients lining the hallways since we were one of the few facilities still providing both of those services," says Turturro. "In 2009 we had 2,150 visits for BH and addiction medicine. In 2012 we had nearly 7,000 visits."
Hospital administrators as well as faculty and staff from Western Psychiatric Institute and Clinic of UPMC were all focused on the problem, but they realized that meaningful solutions were going to require a more comprehensive view, explains Turturro. "We pulled all of the stakeholders together to try looking at this as a community and as a region rather than as an individual hospital or an individual health system," he says.
This collaborative approach produced several interventions that have succeeded in not only easing some of the pressure on the ED, but also in reducing wait times and lengths of stay (LOS). Further, patients with MH or addiction-related issues are being linked with the kind of care and resources that they need in a much more expeditious fashion, says Turturro.
Such swift progress in tackling an increasingly complex set of issues has attracted the attention of Urgent Matters, a national initiative funded by the Robert Wood Johnson Foundation, which recently presented to UPMC its Emergency Care Innovation of the Year Award.
Enlist assistance of crisis workers
One of the most visible changes that has been implemented in the ED is the addition of front-line workers who essentially triage patients who have presented with MH or addiction needs. "These are workers from an outpatient, mobile crisis center [called re:solve] who we have hired to work for us," explains Turturro. "What these people do is work with patients to determine if their needs require hospitalization or if they primarily have social needs that are exhibiting themselves in a MH kind of a complaint."
The re:solve workers are primarily bachelor's-level clinicians who have demonstrated abilities to perform MH-crisis services, explains Ellie Medved, RN, MSN, vice president of ambulatory services at Western Psychiatric Institute and Clinic. "They maintain their crisis identity, so they are still part of the crisis program," she says.
Patients are always evaluated by emergency providers first to take care of any medical needs and perform medical screening exams; however, many of these patients still have social or BH issues that need to be addressed. In these cases, the emergency provider will hand the patient off to one of the crisis interventionists to work with them, notes Medved.
"What we wanted to do was some type of intervention that would expedite that ED visit, but then also give the person some tools or resources that might prevent future presentations to the ED," says Medved. "So the emergency staff will identify the person, and then the crisis program staff will work with the individual while [he or she] is in the ED to help him or her transition back to the community."
For instance, there might be a housing or transportation issue, or there might be a need for long-term outpatient treatment, says Medved. "The [crisis interventionists] take a problem-identification-and-solving type of approach in the ED to get the person linked up with whatever they might need that brought them to the ED," she says.
Leverage community resources
The crisis interventionists are well-versed in what resources are available in the community because this type of knowledge is a backbone of the region's crisis program. "We have to know what is out there, and we have made hundreds and hundreds of visits to different community services, whether they involve housing, shelters, food banks, formal or informal treatment providers for behavioral health, spiritual organizations, or law enforcement," explains Medved. "This is one of the reasons why we keep the [ED-based crisis interventionists] as part of the re:solve staff — so they can maintain the integrity of, and stay linked with, the program."
When the crisis interventionists work with patients, they don't create a typical ED discharge plan; it's more of a game plan for how the person can get through their crisis, adds Medved. "They're not doing treatment planning, and they're not focused on diagnosing," she says. "They're focused on what the person's presentation is, and what kinds of skills and strengths they have to help them get through [their current crisis]."
For instance, it is very common for people who have MH or substance abuse problems to come to the ED when they need some type of intervention because the ED is one resource that is readily available, notes Medved. "Knowing that people seek intervention in the ED when they are feeling really lousy, we wanted to put an intervention in there that they could access," she says. "The idea is to give people skills and tools that can prevent them from having to rely on ED services, and train people on how to use community services."
The roll-out of the approach in the ED, which began in January 2013, went smoothly, which was a bit of a surprise to Medved. "I thought it would be bumpier than it was, but interestingly enough, the emergency staff and [the crisis interventionists] found their way working together," she says. "The ED staff have embraced the crisis workers because EDs are busy places, and all hands are appreciated."
Further, ED providers understand that the types of issues that the crisis interventionists deal with are typically not addressed in the ED, so they are relieved to have the added resource, notes Medved. "It is frustrating when a person comes in and you can't address all of the issues that you see before you," she says. "The crisis interventionists can pick up on all of those issues."
An added bonus is that there is evidence that the crisis interventionists and emergency staff are picking up valuable techniques and information from each other. "Sometimes the emergency staff are expediting cases on their own because they have learned about a resource that they can share with a patient who doesn't need to be with a crisis worker," says Medved. "They are building off of each other's skills."
There are usually one or two crisis interventionists working in the ED, depending on patient volume. "Their schedules are based on the ED's peak times and days of the week when the ED sees the most patients requiring behavioral health intervention — typically evenings and weekends," adds Medved.
Begin discharge planning sooner
Along with the addition of the crisis interventionists, hospital administrators have also made some other internal changes aimed at speeding throughput and meeting the surging demand for MH services. For example, to free up inpatient beds, the discharge planning process now begins as soon as a MH patient is admitted. "In the past, the common scenario was that someone would be ready for discharge, but needed to go to some type of environment between the hospital and home, and would have to wait several days for that [placement] to occur," explains Turturro. "We have now been able to facilitate that in a much more timely manner, which has created inpatient space."
The hospital has also instituted protocols that essentially get MH patients through their inpatient stays more quickly, adds Turturro.
Further, on the addiction medicine side, the hospital has worked with community partners to make sure that inpatient beds are preserved for those patients who are too sick to be detoxed in outpatient settings. For example, most patients requiring opioid detox services can be managed through an outpatient protocol handled by an outpatient rehabilitation center or an ambulatory detoxification program unless they are at risk for medical decompensation, says Turturro.
Such steps have eased pressure on the ED because BH and detox patients are no longer lining the hallways while they wait for inpatient space. "The only patients we were boarding were psych and detox patients, and our clinical decision unit, which was meant to be used as an extension of the ED, had basically turned into a holding tank for patients who were too sick to leave because they were waiting for a detox or a MH bed," he says. "The clinical decision unit is now being used as it was intended."
In just one year, the interventions UPMC put in place have produced identifiable benefits. The time it takes for a detox patient to be seen in the ED has decreased from one hour to less than 15 minutes, and the time it takes for a patient to be admitted to a detox unit has gone from about 20 hours to six hours, explains Turturro.
"We are tracking the number of people who come in with a BH or addiction chief complaint and we track the number of admissions," he says. "What we are finding is that since we have put these interventions in place, the percentage of patients who are admitted has declined since we are applying that inpatient resource a little more appropriately."
Reach out to other health systems
How much of what UPMC has done is generalizable to other hospitals? It's a question Turturro has pondered quite a bit in recent months. He notes that while every site is going to have its own unique challenges and solutions, there are some lessons other health systems can borrow from the UPMC experience. For example, Turturro advises hospital administrators to take steps toward breaking down the competitive walls that exist between different health systems, and try to approach the demand for MH services as a community. "If everyone pools their resources together, you will find there are gaps that can be filled by one system that may not be present in another system," he says.
Further, Turturro advises hospital administrators to thoroughly investigate what resources are available in their regions. "Until we started looking, we really didn't know how much we had within our community and within our county on the outpatient side that was really being under-utilized," he says. Find a way to tap into all the group homes, detox clinics, halfway houses, and other resources that can help patients get to the point where they can function independently in the community, he says.
To take this one step further, efforts are underway in Pennsylvania to create a statewide database of available beds for MH and addiction medicine so that placement can be found quickly for patients who need these services. "Maryland instituted a voluntary statewide database for these types of beds, and it is being used by about half of the hospitals. It has been useful to frontline clinicians," says Turturro. Such a resource is particularly valuable when you have patients who you cannot discharge because it would be too unsafe, but the ED is not appropriate for the level of care that they require either, adds Turturro.
Many hospital systems may find that they can leverage area crisis services in much the same way that UPMC has done, but Medved encourages hospital and ED administrators to explore all of their options. "If you have a hospital that does not have behavioral health, you really have to start that conversation with a provider to learn about the various levels of care in behavioral health that are available," she says. "In our situation, and I think in many situations, crisis services make the most sense, but there may be other types of individuals or program staff that make sense in your ED."
One other important recommendation is to be sure to reach out to payers to ensure that they will support what you plan to do with MH, adds Medved. "Early on we connected with our payers and regulators just to make sure they were aware of what we were doing and that we had their support to move forward," she says.
It is still too early to predict how healthcare reform will impact UPMC's MH interventions, but Medved would not be surprised to see demand for MH services increase. "People who didn't have access to this before may have access to it now. There may be new people in the system trying to learn how to navigate services," she says. "When those types of things happen, you usually see a spike in the use of crisis services, so that may be the case, but it is too soon to tell."
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