1. How can we partner with community stakeholders to right-size the ED use for acute behavioral health patients?
One-in-eight ED visits is associated with a behavioral health crisis. Further, 45% of ED patients admitted with non-psychiatric complaints also have an undiagnosed mental illness. It's no wonder why providers are looking for solutions to improve management in the ED. Some providers have launched community-based behavioral health support to better manage patients in crisis and divert unnecessary ED use. Here's how the two primary community-based approaches—placing behavioral health care team members in the community and/or offering alternative, specialized community-based sites of care—work.
Place behavioral health care team members in the community to de-escalate crises
The Victoria Department of Health in Australia deploys its award-winning Police, Ambulance, and Clinical Early Response (PACER) program to safely treat acute behavioral health patients in the community. The three-pronged team pairs mental health clinicians with police and ambulance units. PACER responds to emergency behavioral health calls with rapid onsite support including clinical assessments, right site of care recommendations, and social service referrals. The mental health clinician de-escalates potentially dangerous situations for patients and emergency teams and helps to divert unnecessary ED use. PACER decreased the time to mental health assessments for patients in crisis by 66% and decreased ED length of stay for mental health admissions by 33%.
Offer community-based alternatives to ED care
Patients who don't need ED care but still require behavioral health support can be routed instead to a community-based crisis house. Health systems can provide financial support to these facilities to allow them to expand their capacity to meet demand.
For example, Nexus Montgomery funded the expansion of Cornerstone Montgomery, a behavioral health provider in Maryland that provides residential crisis services to stabilize acute patients. Patients typically stay for 10-14 days at one-third of the cost of an inpatient stay. Counselors identify triggers, coping skills, short-term goals for recovery, and crisis prevention strategies. A psychiatrist rotates through the three crisis houses for medication management. An assistant manages referrals and performs administrative tasks. After patients leave the crisis house, staff continue to offer advice and additional assistance when needed to maintain stabilization. Cornerstone Montgomery's crisis houses served 298 patients in fiscal year (FY) 2018, preventing 7,669 inpatient bed days.
2. What should be our scope of palliative care services? Which patients should we target?
The reach of palliative care programs varies widely across provider organizations. No matter the model, all providers should create a standardized, cross-setting definition to guide programming. Organizations new to palliative care services typically start with a narrow scope mostly focused on transitioning patients nearing end-of-life to hospice. Some organizations widen that scope and patient eligibility criteria to then offer advanced illness management. The most advanced organizations broaden services further and offer general symptom management for patients with chronic conditions. Providers choose the scope of their services depending on their mission, program goals, internal readiness, and existing infrastructure, including staff availability to provide palliative care services.