Psychiatric Emergencies: A Continuum of Solutions

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1 C30 These presenters have nothing to disclose Psychiatric Emergencies: A Continuum of Solutions Margie Balfour, MD, PHD John Santopietro, MD William Tucker, MD Facilitator: Mara Laderman, MSPH December 6, :30 2:45 PM #IHIFORUM

2 Session Objectives P2 Describe the challenges that emergency departments face in caring for patients with behavioral health needs. Compare different approaches to addressing psychiatric emergencies in health care and community settings. Understand how to reconfigure their current resources to reduce the number of psychiatric emergencies in the first place. #IHIFORUM

3 Psychiatric emergencies are prevalent P3 In 2007, 12 million, or 12.5% of total ED visits, were related to mental health and substance abuse. In 2014, 84 percent of EDs reported boarding psychiatric patients with over half reporting at least daily boarding. 91% of physicians who report psychiatric boarding in the ED say that boarding has resulted in harm to other patients or staff.

4 and lead to poorer outcomes and P4 higher costs Overcrowding in the ED Delays in treatment for psychiatric patients which increases the probability of inpatient admissions Treatment delays for other ED patients Increased stress for patients and families Increased pressure and stress for ED teams Safety concerns for health care professionals Financial issues

5 Session Format P5 Panel discussion: Each presenter will speak for 15 minutes Q&A and discussion

6 Caring for ED Patients Virtually : A Local Story John Santopietro, MD, DFAPA Carolinas HealthCare System IHI December 6 th, 2016

7 W H E R E W E A R E

8 Carolinas HealthCare System 39 hospitals and 900+ care locations in North Carolina, South Carolina and Georgia More than 7,800 licensed beds More than 11 million patient encounters in ,000+ system-employed physicians, 14,000+ nurses and more than 60,000 employees $1.5 billion in community benefit in 2013 More than $8 billion in annual revenue The region s only Level I trauma center One of five academic medical centers in North Carolina One of the largest HIT and EMR systems in the country Cerner s largest contract

9 A good place to start

10 Source: Anne M. Hakenewerth, PhD, Texas Cancer Registry, Texas Department of State Health Svcs. Judith E. Tintinalli, MD, Anna E. Waller, ScD, Amy Ising, MSIS, Tracy DeSelm, MD, Carolina Center for Health Informatics, Department of Emergency Medicine, University of North Carolina at Chapel Hill

15 Behavioral Health is another vital sign Normalize Destigmatize Systematize

Virtual Behavioral Health Footprint Tele-psychiatry and Patient Placement

Collaborate with 50 + Primary Care sites* Behavioral Health Call Center Map Key

Future Tele-psychiatry and Patient Placement Site Active BHI Site Future BHI Site

16 Virtual Behavioral Health Footprint Tele-psychiatry and Patient Placement Collaborate with 20 Emergency Departments Behavioral Health Integration (BHI) Collaborate with 50 + Primary Care sites* Behavioral Health Call Center Map Key Received 175,954 calls in 2015 Active Tele-psychiatry and Patient Placement Site Future Tele-psychiatry and Patient Placement Site Active BHI Site Future BHI Site BH Call Center *Note: Numbers include care management. There are 16 fully integrated PCP sites.

17 A new idea?

20 Department Evolution FTE Shortage The Plan Scheduling Capacity with Current FTEs (not including OT & PRN) Patient Placement Monday Friday 7 am to 11 pm Actual Scheduling by 2014 Year End 24/7 Telepsych Monday Friday 7 am to 11 pm Weekdays: hrs* Weekends: hrs* 2014 OT & PRN Hours 5,926 2, Physician Supplemental Pay n/a *need data* *Currently, telepsych clinician and MD scheduling times differ Director 2014 Jan Feb Mar April May June July Aug Sept Oct Nov Dec 1.0 FTE Nurse Manager 25% Admin Prog. Coordinator 50% Admin Telepsych Clinician Placement Coordinator MD Coverage 3.0 FTEs 1.0 FTE 1.0 FTE 1.0 FTE 1.0 FTE.5 FTE 1.0 FTE 1.0 FTE 1.0 FTE 3.0 FTEs 1.0 FTE 1.0 FTE Incremental Existing 11/28/

22 2014 Incremental CHS Investment $ 40,873 for.96 Admission Transfer Coordinator (annualized) $ 85,003 for 1.17 Telepsych Clinicians (annualized) $ 151,689 for overtime and PRN (patient placement & telepsych) $ 339,300 for G4S Patient Transport Contract $ 0 for Providers (utilized existing ED Physicians) $ 629,991 in incremental expense to CHS in /28/

24 ED Length of Stay Reduction 50 ALOS for CMC Pineville ED BH Patients 24

27 No rest for the weary 8000 Acute Care ED Patients (excluding psych ED) % September 2014 YTD Acute Care ED Patients (excluding psych ED) September 2016 YTD Linear (Acute Care ED Patients (excluding psych ED))

28 .

29 Workshop C30 This presenter has nothing to disclose Facility-based behavioral health crisis services as an alternative to ED boarding and jail Margie Balfour, MD, PhD VP for Clinical Innovation & Quality, ConnectionsAZ Chief Clinical Officer, Crisis Response Center Asst Professor of Psychiatry, University of Arizona Tucson, AZ Tue Dec :30-2:45 #IHIFORUM

The path to psychiatric boarding P30 People in crisis are often unable to immediately access care or they don t know where to go So they go to the ED Which is not

30 The path to psychiatric boarding P30 People in crisis are often unable to immediately access care or they don t know where to go So they go to the ED Which is not equipped for psychiatric evaluation, stabilization, or discharge planning So they get put on a list to be admitted to an inpatient psychiatric unit And then they wait and wait

31 How do people get to the ED? P31 First Responders Walk-in For psych emergencies, first responders are often the police

1 Nearly half of people with SMI have been arrested at least once. 2 SMI 3 -Men -Women Prevalence of Mental Illness Jail US Adults 5 17.1% 34.

32 P32 The path to jail Officers want the person to get treatment But they don t know where else to take them except the ED Where they have to wait. Cops are busy and have crimes to fight So they take the person to jail instead. There are over 2 million jail bookings of people with serious mental illness (SMI) each year. 1 Nearly half of people with SMI have been arrested at least once. 2 SMI 3 -Men -Women Prevalence of Mental Illness Jail US Adults % 34.3% 4% Any mental disorder 4 76% 18% + Co-occurring substance use 4 49% 3.3% 6 1. Steadman HJ et al. (2009) Prevalence of serious mental illness among jail inmates. Psychiatric Services. 60(6): %. Hall LL et al. (2003) TRIAD Report: Shattered Lives: Results of a National Survey of NAMI Members Living with Mental Illnesses and Their Families. 3. Includes PTSD. Excluding PTSD rates are 14.5% for men and 31.0% for women. Steadman HJ, Osher FC, Robbins PC, Case B, Samuels S. (2009) Prevalence of serious mental illness among jail inmates. Psychiatric Services. 60(6): Glaze LE, James DJ. (2006) Mental Health Problems Of Prison And Jail Inmates. Bureau of Justice Statistics. 5. NIMH Statistics 6. SAMHSA (2015). Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health.

An alternative model P33 A facility-based behavioral health crisis program that provides 24/7 on-demand access A safe and welcoming environment Rapid triage and psychiatric assessment Crisis

33 An alternative model P33 A facility-based behavioral health crisis program that provides 24/7 on-demand access A safe and welcoming environment Rapid triage and psychiatric assessment Crisis Stabilization: Via counseling, medications, peer groups, family engagement, etc. Connection to community resources Studies show this model reduces: ED boarding 1,2 Inpatient hospitalization 1,2 Arrest 3 1. Little-Upah P et al. (2013). The Banner psychiatric center: a model for providing psychiatric crisis care to the community while easing behavioral health holds in emergency departments. Perm J 17(1): Zeller S et al. (2014). Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med 15(1): 1-6.Steadman HJ et al (2001). A specialized crisis response site as a core element of police-based diversion programs. Psychiatr Serv 52: Steadman HJ et al (2001). A specialized crisis response site as a core element of police-based diversion programs. Psychiatr Serv 52:219-22

An example: Crisis Response Center 34 Built with county bond funds in 2011 to serve Pima County (Tucson, AZ) 12,000 adults + 2,200 youth per year Alternative to jail, ED, hospitals Co-located crisis

34 An example: Crisis Response Center 34 Built with county bond funds in 2011 to serve Pima County (Tucson, AZ) 12,000 adults + 2,200 youth per year Alternative to jail, ED, hospitals Co-located crisis call center Mobile team dispatch Bed board Space for community partners Adjacent to Mental health court (civil commitment) Inpatient psych hospital that provides court-ordered evaluations Emergency Department ConnectionsAZ/Banner University Medical Center Crisis Response Center in Tucson, AZ

24/7 Access to Psychiatric Emergency Services 35 Patients arrive via: Walk-in Law enforcement Emergency rooms transfers Mobile Crisis Teams Referrals from clinics, foster

35 24/7 Access to Psychiatric Emergency Services 35 Patients arrive via: Walk-in Law enforcement Emergency rooms transfers Mobile Crisis Teams Referrals from clinics, foster care, group homes, etc. Services include: Urgent care clinic 23-observation unit Short-term (3-5 day) inpatient stabilization We address any behavioral health need at any time.

36 Low clinical barriers to access 36 No wrong door We do our best to take everyone: No such thing as too agitated Highly intoxicated Voluntary or involuntary Fewer medical exclusionary criteria than many inpatient psych hospitals No refusal policy for law enforcement Otherwise, where would these patients go?

hurt themselves or others, while being as comfortable

37 37 The CRC provides safe environment where people can be under continuous observation and lack the means to hurt themselves or others, while being as comfortable and welcoming as possible Crisis Response Center, Tucson AZ

38 Gated Sally Port for Secure Law Enforcement Drop-offs 38 Crisis Response Center, Tucson AZ

) Diversion from inpatient: 60-70% discharged to the community the following day Early intervention Median door to doc

39 39 23-Hour Observation Unit Staffed 24/7 with MDs, NPs, PAs Medical necessity criteria similar to that of inpatient psych (danger to self, other, etc.) Diversion from inpatient: 60-70% discharged to the community the following day Early intervention Median door to doc time is ~90 min Interdisciplinary team Including peers with lived experience Aggressive discharge planning Collaboration and coordination with community & family partners Assumption that the crisis can be resolved

40 Outcomes: Police Turnaround Time 40 Half of our patients arrive via law enforcement. They are an important customer and quick turnaround time is critical to providing a viable alternative to jail. (Our Phoenix facility achieves similar results with twice the volume.)

41 Outcomes: Urgent Care Clinic 41 Patients are able to walk in and quickly get their needs met without going to an ED (med refills, connection to services, etc.)

42 Outcomes: Obs Unit Door-to-Doc 42 Early assessment and treatment is critical to avoiding hospitalization and preventing adverse outcomes such as restraints and assaults.

43 Outcomes: Community Dispositions 43 Only a fraction of the observation patients are admitted to an inpatient unit. Instead, they can be discharged (diverted) to less-restrictive communitybased care. In an ED, many more would board waiting for beds.

44 44 More outcomes and data We developed a set of quality measures for our organization Endorsed by the American Association for Emergency Psychiatry The Joint Commission will have a project in 2017 to develop a core measure set for behavioral health crisis services. We also created daily data feeds to the Regional Behavioral Health Authority to assist them more real time management of network performance, identify high-utilizers, etc. Balfour ME, Tanner K, Jurica PS, Rhoads R, Carson C. (2016) Community Mental Health Journal. 52(1):

45 More outcomes and data Internal Quality Metrics We developed a set of quality measures for our organization Endorsed

health system We developed daily data feeds for the Regional Behavioral Health Authority (our primary payer) Real time

45 45 More outcomes and data Internal Quality Metrics We developed a set of quality measures for our organization Endorsed by American Association for Emergency Psychiatry Joint Commission project in 2017 will develop core measures for crisis services. System Performance Data Crisis utilization is a canary in the coal mine performance indicator of the overall behavioral health system We developed daily data feeds for the Regional Behavioral Health Authority (our primary payer) Real time analysis of network performance Identification of high utilizers Balfour ME, Tanner K, Jurica PS, Rhoads R, Carson C. (2016) Community Mental Health Journal. 52(1):

Other applications of this model 46 Urgent Psychiatric Center Our flagship facility in Phoenix,

across metro Phoenix We have also assisted in the design and implementation of similar programs

The Banner psychiatric center: a model for providing psychiatric crisis care to the community

46 Other applications of this model 46 Urgent Psychiatric Center Our flagship facility in Phoenix, serving 2000 patients per month We adapted this model to service a hospital system with EDs across metro Phoenix We have also assisted in the design and implementation of similar programs in more rural areas such as Flagstaff and Prescott Valley Little-Upah P et al. (2013). The Banner psychiatric center: a model for providing psychiatric crisis care to the community while easing behavioral health holds in emergency departments. Perm J 17(1):

47 Lessons Learned P47 The solution is not always more beds. Inpatient admission is often the default when less-restrictive alternatives are unavailable or ineffective. Quickly meeting people s needs leads to positive outcomes. Figure out how to say yes. When crisis centers exclude patients, they end up in EDs/jails. Safety is the prime directive. Processes and facilities must be designed to safely care for the most acute. A multidisciplinary approach and community partnerships are critical to success. There will never be a rule for every scenario. When in doubt: 1) be safe, and 2) follow the golden rule.

48 How to Reduce Pressure on Psychiatric Emergency Services Promote Recovery Instead of Compliance William Tucker, MD

49 Problems with Current Services Former inmates, mental hospital dischargees, and the homeless are NOT YET engaged in community services Clinics to which the above are referred have no motivation to hold onto them. Institutions themselves have no resources to promote community engagement ER is always the default option (+/- hosp.) Hence, the revolving door is the rule

50 Sources of Increasing Pressure 1) increased access provided by funding through the Affordable Care Act 2) increased rate of early discharge from mental hospitals and from prisons (high cost of institutionalization->closures)

51 Alternative to Revolving Door : Stabilization and Recovery Stabilization=independent living, financial stability, acceptance of [selected] traditional services [e.g., meds, programs], avoidance of ER s, reduction/ cessation of substance abuse Recovery=pursuit of personal goals (patients have provided a standard list of these shelter, transportation, meaningful relationships, etc; more specifically: living undisturbed, independence from family, pursuit of pleasurable activities, college completion, freedom from agency interference, gender identity transformation)

52 How Outreach Works to Promote Recovery It provides traditional services (psychopharm, supportive psychotherapy) + non-traditional ones (making home visits and visits to ER s, in-patient sites, PMD s, job sites) It requires getting to know each patient intimately (i.e., personal goals rather than symptoms) It requires hanging on until stabilization and recovery begin (note: Promoting compliance leaves responsibility with the clinician, rather than with the patient)

53 Resources and Outcomes 1) I treated 30 patients at a time, working 2d/wk +consulted to a Psych NP treating another 30. 2) Medicaid contract paid $1500/mo. for mental health and housing (SSI supplemented housing). 3) Half of my patients recovered. 4) Hospitalizations and ER visits plummeted for all patients, more than off-setting costs.

54 Problems with Outreach It requires working in the community, which is not as safe, secure, and predictable as in traditional institutional or clinic settings. It requires lots of LEGWORK! It s an open-ended contract: there are no discharges or hand-offs to other services. It takes a team. 50% of patients will require enhanced interventions, but you don t know which 50%.

55 How to Get Outreach Started Get administrative support for market-rate community housing, not group homes. Divert a SMALL amount of current resources to ACT teams, or set up referral networks. Have ER assign new patients to ACT teams. Help families connect early to services promoting recovery. Check out programs for enhanced firstepisode services (RAISE, OnTrack).

56 My Questions to You About Systems Change Does outreach sound possible within your system? What changes would you require to try it out? Have you been thinking of outreach for a long time already, waiting for your system to catch up?

57 Questions?

Psychiatric Emergencies: A Continuum of Solutions Margie Balfour, MD, PHD John Santopietro, MD William Tucker, MD Facilitator: Mara Laderman, MSPH

C30 These presenters have nothing to disclose Psychiatric Emergencies: A Continuum of Solutions Margie Balfour, MD, PHD John Santopietro, MD William Tucker, MD Facilitator: Mara Laderman, MSPH December