By Dorothy Brooks
While EDs across the country saw a surge in patients with behavioral health concerns during the pandemic, Norfolk, VA-based Sentara Health, a system which includes 15 hospitals across the state, faced added pressures contributing to the phenomenon. “This surge peaked in 2021 when five of Virginia’s state psychiatric hospitals had to close to new admissions due to staff shortages,” explains Ken Dunham, MD, FAPA, CPE, the executive director of medical operations for behavioral health at Sentara. “In this COVID-era of healthcare, staff shortages had become commonplace, especially in behavioral health, as more people sought out care.”
As a nonprofit safety-net institution, health system leaders realized things would need to change to better serve the community, states Dunham. Consequently, the health system embarked on a process of improvement and redesign that began with a comprehensive look at how behavioral health patients who presented to Sentara EDs were being managed.
“We wanted to find efficiencies and best practices that would help our patients get to the right level of service at the right time,” he tells EDM. “This meant paying special attention to our ED patients with behavioral health issues.”
While the push for improvement is ongoing, the results thus far are impressive. Administrators report that ED length-of-stay for behavioral health patients has decreased 13% even though volume continues to surge. Further, the health system has put into place an infrastructure that can continue to evolve and adapt to meet community and health system needs going forward.
To begin the process of improvement, Sentara assembled what Dunham refers to as a high-
performance team (HPT), composed of a diverse range of experts across the system, including representatives from the ED, behavioral health, hospitalist medicine, nursing leadership, and others. “The HPT identified needs, resources, best practices, efficiencies, and opportunities. In the end, we had four buckets of innovations,” states Dunham. These include:
• a centralized assessment team of therapists that used best practices and created system efficiencies;
• more psychiatric physician help;
• evidence-based means to risk-stratify patients, which included behavioral health-specific triage protocols;
• projects that enhanced connections to behavioral health providers for patients being discharged from the ED, and alternatives to the ED for behavioral health patients.
Dunham explains that Sentara created a system called the Psychiatric Emergency Response Service or PERS. “Staff were mostly therapists and nurses with behavioral health experience,” he says. “We used a hybrid program that included telehealth assessments as well as face-to-face evaluations. This would augment the emergency medicine provider’s decision-making and would also help with patient navigation.” Dunham adds that under this process, opportunities to resolve the cases of more complex patients could be escalated across the system — an approach that helped to reduce siloed care.
While the Sentara Health System has four inpatient psychiatric units, the psychiatrists in these units were already busy managing their inpatient duties, so the HPT endeavored to find alternative solutions to handle the increasing need for emergency and med/surg psychiatric consultations. “One of our facilities had already been using a telepsychiatry vendor, [and] the facility had good data on how the partnership had reduced [the length of stay for behavioral health patients in the ED],” notes Dunham. “We decided to engage the vendor to expand their footprint and created a stepwise plan to expand their reach to other Sentara facilities.”
Using the vendor has given the health system time to determine how to create its own sustainable psychiatric consultation program, observes Dunham. Also, he says that the HPT team started pilot projects aimed at getting patients discharged from the ED connected with psychiatry resources in the community with next-day appointments.
Other steps involved the implementation of evidence-based screening processes for suicide and the development of a process to quickly identify behavioral health patients at low risk who can be discharged to outpatient resources. Dunham notes his experience in using artificial intelligence to improve behavioral health workforce efforts prompted him to work with a data scientist to produce a more effective risk-stratification program.
“We’ve done a proof of concept to show that we can use a machine learning/artificial intelligence program that can successfully predict which patients can be discharged to a lower level of care from the ED without needing a full assessment from a therapist,” says Dunham. “We want to use this data to create a meaningful risk level so that the ED provider can decide if [he or she] wants to consult with the behavioral health team for a full assessment vs. having a behavioral health navigator help the patient find the most appropriate outpatient resource.”
The idea behind this process is to preserve the behavioral health therapists for patients who require more nuanced evaluation and assessment, explains Dunham. “After we get this program up and running, our next step would be to figure out which patients are at high risk for return to the ED for a suicide attempt, and then attempt to intervene with these patients,” he says.
The final bucket of innovations pertains to how Sentara EDs interact and connect with outpatient behavioral health resources, which often are difficult to track, states Dunham. “We created resource documents and discharge navigation experts that could help get patients discharged to the right place at the right time,” he says. “We then make sure we keep these [resources] updated since the behavioral health landscape tends to change.”
Dunham notes that the health system also has started projects to facilitate the nighttime establishment of appointments with outpatient behavioral health providers. “That way, we don’t have to wait until the next business day to discharge patients with a complete discharge appointment date and time,” shares Dunham. “We can discharge them at 2 a.m. with a confirmed follow-up appointment, sometimes with same-day or next-day time slots.”
Dunham says that change management was critical to implementing all of these processes at the different Sentara facilities, each of which has unique goals and needs. “We realized that there is no such thing as a single, centralized solution that is perfect for every facility, so we continuously evaluate and support projects that are facility-specific, based on the local needs of that community and their hospital leadership,” he says. “Also, we have been given strong analytic support to reach our goals. This has been key to evaluating our progress and opportunities.”
In the future, the health system intends to push further upstream with behavioral health solutions. “We all know that our EDs should be a last choice, not the only choice, and not the community’s easy choice,” says Dunham. “Systems like Sentara need to create an easy button to navigate patients away from the ED to an appropriate level of care.”
However, once patients get to the ED, the safest solution is usually the one that gets them to the appropriate level of care as efficiently as possible, explains Dunham. “Very often, the community has significant gaps in available levels of care. Sentara will continue to evaluate which gaps [we] should fill, and which [gaps should be filled] with partners in the community.”
Having achieved significant success with the processes implemented thus far, Dunham tells colleagues who are looking for more effective ways to manage ED patients with behavioral health concerns that there is probably not a single solution to the problem. “It really does take multiple solutions to effectively triage, treat, and disposition patients with behavioral issues,” he says. “The lowest-hanging fruit is usually adding behavioral health expertise to the ED assessment process; [however], the longest-lasting solution will be forging partnerships with behavioral health providers that can divert patients from the ED or are able to take patients out of your ED for treatment.”
