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Struggling with behavioral health patients in your ED? You're not alone.

September 11, 2019

    Of all the questions care transformation leaders have asked our Population Health Advisor team so far in 2019, one topic is consistently top-of-mind: behavioral health. While questions about how best to manage population behavioral health needs aren't new, the questions we receive are growing in both volume and nuance.

    Primer: Right-size ED utilization for acute behavioral health patients

    In particular, your peers are increasingly interested in ways to address behavioral health needs without burdening your ED. Here are three ways you can meet your patients' behavioral health needs—without straining ED resources.

    1. Establish a crisis stabilization units (CSUs)

    CSUs allow patients experiencing behavioral health crises (e.g., suicidal intent) to receive appropriate care, while simultaneously improving throughput in the traditional ED. The busyness of the ED creates a poor environment to de-escalate psychiatric crises. Designating a separate space to care for these patients frees up staff time to effectively treat other patients in the ED. That's why we see providers who have both high demand for behavioral health care in the ED and access to inpatient psychiatric beds increasingly investing in CSUs.

    For instance, Intermountain's McKay Dee Hospital in 2017 opened a CSU, called the Behavioral Health Access Center, next to the ED. Intermountain over the previous five years had seen a 33% increase in ED visits related to behavioral health crises. Intermountain's Access Center provides crisis treatment and triages patients to inpatient care when needed, which is about half of the time, at one-third the cost of an ED visit. Within one year, Intermountain's ED saw a 50% decrease in psychiatric crises.  

    2. Equip your ED with on-demand behavioral health expertise

    However, while CSUs have a positive impact on ED efficiency and care quality, they are not the whole answer to addressing poorly managed ED utilization among behavioral health patients. An increasing number of providers are investing in other strategies, too.

    For instance, Atrium Health found an innovative way to address how EDs, while a common access point for patients with behavioral health conditions, often deprioritize behavioral needs as co-morbidities to physical ailments. Specifically, Atrium established a centralized tele-mental health service to link its ED to behavioral health experts using tele-consults. These consults provide a new upstream access point for patients and allow non-behavioral health staff to operate at the top of their license in the ED. Following the launch of Atrium's tele-consults, ED volumes surged by 37% between 2015 and 2017, but median ED visit time saw a 2.5-hour drop.  

    3. Establish a comprehensive transitional care model

    Separately, Massachusetts General devised another strategy to address how many patients presenting to EDs with behavioral health needs lack a regular source of care. Massachusetts General's Substance Use Disorder (SUD) Initiative bridges the gap between acute and ongoing services. Each of its three components plays a role in supporting transitional care management for patients struggling with SUD:

    1. The walk-in Bridge Clinic provides immediate SUD care for patients who don't require ED-level services and who don't have a regular source of care or need support while waiting for a primary care visit.

    2. The inpatient addiction consult team develops long-term care plans and makes patients aware of the Bridge clinic as an option for transitional care support.

    3. Community health clinics provide ongoing SUD services, including peer recovery coaching and medication-assisted treatment.

    For more information on Mass Gen's approach, check out our blog post.

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