Burke Center Mental Health Emergency Center

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1 Burke Center Mental Health Emergency Center Avrim Fishkind, M.D. JSA Health Telepsychiatry Susan Rushing Executive Director Burke Center

2 Objectives Define the modern purpose of Psychiatric Emergency Services: Community Safety Net Understanding how to build coalitions to start new services: Creating a groundswell Understand the obstacles to providing rural psychiatric emergency services Service Issues Understand the use of telemedicine in emergency settings: Technical / Clinical Issues

3 n n n n Reduce hospital admissions and readmissions. Provide methods for effective diversion from hospital, jails, CMHC services wrap around Provide care wherever it is needed using mobile outreach if necessary Avoid coercion of the patient; offer choices for crisis treatment which maintain least restrictive community functioning I. Comprehensive Psychiatric Emergency Services Principles of Delivery

4 n n Offset the cost of emergency assessment with more efficient, cost effective alternatives to hospitalization. Provide definitive treatment when possible n Extended Observation can mediate a crisis within 24 hours n n Children can be treated / discharged without family or school disruption Educate families to assist consumers in avoiding future mental health crises I. Comprehensive Psychiatric Emergency Services Principles of Delivery

5 Psychiatric Emergency Service 23 Hour / 72 Hour Observation Crisis Residential Services Crisis Stabilization Units Community Residential Units Respite Care Mobile Crisis Outreach / Wrap Around Crisis Counseling Services Also, Hotline, VNS, Consumer Respite Allen MH, Forster P, Zealberg J, et al. APA Task Force on Psychiatric Emergency Services: Report and recommendations regarding psychiatric emergency and crisis services. American Psychiatric Association; 2002.

6 Burke Center Established 1974 Governmental sponsored by counties 9 member Board of Trustees JCAHO MH IDD SA ECI II. Burke Center

7 Burke Center Based in Lufkin, Texas 12 Counties 11,000 square miles Population = 370,000 II. Burke Center

8 Funding cuts Rising costs > 20% uninsured System at capacity Medically Underserved Area Health Care Professional Shortage Law Enforcement Challenges Mental Health Care Professional Shortage No other comprehensive providers Lost 84 inpatient beds No Money, No Ride II. Burke Center: Obstacles

9 Lufkin to El Paso Katrina Rita 20% increase in hospitalizations Incidence 2x state average Filled all beds Overflow to hospitals and jails Frustrated and outraged III: Galvanized to Action The Tipping Point

10 Reached out for partners Decided to shine a light on the problem Wrote and got-- HRSA Network Development Planning Grant Needs Assessment: Done by university What are the processes, problems, and solutions? Interviewed wide range of stakeholders across the region Every county included III. Galvanized to Action

11 Insufficient behavioral health resources Insufficient preventive and supportive care Resource Juggling Responsibility and cost shifting Problems in data collection Isolation Interview subjects debriefed Discussed the scope of the problem Solicited ideas Recruited to form local advisory boards in each county These groups provided forums for local problem solving III. Galvanized to Action Findings

12 Concept mapping in each county Gathered ideas-action statements Sorted into clusters Ideas ranked within clusters Aggregated across all counties County plans Regional plan Each local board represented on Regional East Texas Network Board Invited legislators to the meetings United behind the plan Early wins kept momentum III. Galvanized to Action Regional Planning

13 Educate the legislature on impact of cuts Training on MH emergencies for ER staff Jointly developed protocols for MH emergencies- Burke, law enforcement, EDs, 8 general hospitals Develop local alternatives for crisis care that minimize law enforcement time and ER involvement III. Galvanized to Action Regional Planning

14 Quantified the cost of the status quo 500 $6,ooo = $ 3 million Top legislative priority region wide Stakeholders spoke with one voice Celebrated the appropriation Went after $$ for our project III. Galvanized to Action Executing the Plan

15 Hospitals - $400k annual cash match Counties - $180k annual cash match T L L Temple Foundation fund new construction State - $1.66m annual grant funding T L L and Nacogdoches Medical Center temporary quarters Burke Center start up, renovations III. Galvanized to Action Executing the Plan

16 Comprehensive Psychiatric Emergency Program Model Psychiatric Emergency Service Extended Observation Unit Crisis Residential Unit Mobile Crisis Outreach Team IV: Mental Health Emergency Center: Program Description

17 Adults Voluntary or Involuntary Walk in or Transported by Law Enforcement Open Door Policy with minimal exclusion criteria IV: Mental Health Emergency Center: Program Description

18 Psychiatric Emergency Service (PES) Voluntary / Involuntary Receiving Multidisciplinary Team: RN / CSW / Telepsychiatrist Non-Coercive approach without restraint or seclusion rooms Base for Transfer to EOU/ CRU/MCOT/Home/Hospital IV: Mental Health Emergency Center: Program Description

19 Extended Observation Unit (EOU): Voluntary or Involuntary locked unit 6 beds High Acuity Inclusion Criteria with capacity for 1:1 observation Procedures include detailed precautions ( suicide, violence, falls ), vital signs monitoring, EKG, PO intake and output, stat laboratory monitoring from local clinic/hospital. Rapid bio-psychosocial interventions including pharmacotherapy, urine drug screens, detoxification, cognitivebehavioral interventions, and problem solving methodologies IV: Mental Health Emergency Center: Program Description

20 Crisis Residential Unit (CRU): Voluntary 16 beds Bio-psychosocial Programming more involved cognitivebehavioral crisis interventions, family and significant other meetings Daily group meetings that focus on problem-solving and communication skills 3.5 day length of stay but can stay up to 14 days IV: Mental Health Emergency Center: Program Description

21 Mobile Crisis Outreach Team (MCOT): Serves 4 of 12 counties Can transport to telemedicine clinics at 4 locations to see the psychiatrist 30 days initial authorization up to 90 days total service Emphasis on problem solving reasons for non-compliance, cooccurring disorders, and transportation issues Wrap around services pre and post MHEC services IV: Mental Health Emergency Center: Program Description

22 Referrals from: Law enforcement Hospital EDs Outpatient mental health clinics Local public agencies Judges Other first responders including Mobile Crisis Families / NAMI IV: Mental Health Emergency Center: Program Description

23 Triage Phone Call All initial calls to RN at MHEC Establish a mental health emergency Identify potential life threatening medical co-morbidities IV: Mental Health Emergency Center: Program Description Phone Triage

24 Post Triage Direct Admission to MHEC Refer to ED for Medical Clearance Mobile Crisis Screener to ED for further eval IV: Mental Health Emergency Center: Program Description Phone Triage

25 RN assessment completed with Social Worker within 15 minutes of arrival. Medical Protocols prevent transfers to EDs for medical clearance: IV: Mental Health Emergency Center: Program Description On Site Triage

26 Telepsychiatry: Telepsychiatry in the Emergency Department: Overview and Case Studies. Publication of the Abaris Group for the California Healthcare Foundation. Available on the web at Yellowlees, P., M. Burke, S. Marks, D. Hilty, and J. Shore Emergency Telepsychiatry. Journal of Telemedicine and Telecare 14; Shore JH, Hilty DM, Yellowlees P. Emergency management guidelines for telepsychiatry. Gen Hosp Psychiatry 2007;29: V. Mental Health Emergency Center: Use of Telepsychiatry

27 Building on a tradition that dates from the late 1950 s 1956: Providing one way lectures to rural hospitals 1968: Dartmouth Dept. of Psychiatry simultaneous audio/video consult to rural hospital 1973: Dwyer at Mass General using close circuit television to see patients at a nearby airport + P/T/Z V. Mental Health Emergency Center: Use of Telepsychiatry

28 Overcomes need to have face-to-face psychiatrist available 24/7/365 Cost savings substantial versus keeping the MHEC manned with a psychiatrist at all times Using trained emergency psychiatrists makes doing more complex crisis and medical interventions doable in house and prevents mandatory ED medical clearance V. Mental Health Emergency Center: Use of Telepsychiatry - Advantages

29 Emergency Psychiatrists = More Medical Problems to be Handled On Site Alcohol, opiate and benzodiazepine W/D Anaphylaxis and Dystonic reactions Overdoses Hypertension Seizures Community Acquired Infections Seizure Management Diabetes Management: Sliding Scale Insulin and Standing Asthma Mild - Moderate Pain Chest Pain EKGs, Pulse Oximeter, Blood Sugar Finger Sticks IV: Mental Health Emergency Center: Use of Telepsychiatry

30 Telemedicine makes it possible to handle emergencies in a distributed area across 12 counties at 4 different sites without the psychiatrist travelling. Emergency psychiatrists excel at non-coercive interventions and minimal, targeted psychopharmacology reducing the need for seclusion, restraint of injectable medications. Telemedicine can be more tolerable than face to face encounters, especially for paranoid or personality disordered patients.

31 No diagnosis appears unmanageable via emergency telepsychiatry in this project Clear procedures and good communication between the telepsychiatrists, nursing staff, social workers, and MHEC administration are essential in the same way as if all staff were in the same location. Thorough selection and testing of video-conference systems to ensure technology is never part of the problem. Training of all staff in operation of equipment and emergency procedures if equipment is unavailable. V. Mental Health Emergency Implementation Key Points

32 Outcome Measures: Access Diversion Satisfaction V. Mental Health Emergency Center: Outcome Measures

33 Opened December 08 in temporary location Served 995 persons in first year New Facility Opened Winter 2010 Stakeholder Oversight ongoing Track, measure ROI Legislative priority---expand capacity V. Mental Health Emergency Center: Outcome Measures

34 Demonstration of the principle that all mental health emergencies do not have to pass through and ED Decreased law enforcement time in ED Less transportation to remote inpatient hospitals are consumers are diverted to MHEC and if hospitalized, transported by MHEC staff V. Mental Health Emergency Center: Outcome Measures

35 2011 Data: 32% decrease in state hospital bed utilization ~2750 admission to MHEC since inception ~15% need to be transferred to a higher level of care No sentinel events No missed telemedicine connects in > 3 years V. Mental Health Emergency Center: Outcome Measures

36 Chart Title No Answer 0 Very Dissatisfied 1 Dissatisfied 2 Neutral/Don't Know 4 Satisfied 6 Very Satisfied V. Mental Health Emergency Center: Outcome Measures

37 I m glad that there may be hope for self and that my life has not come to an end mentally as well as physically. Thank you The only things is that I can t shake the doctor s hand I m so glad that I was able to talk to someone who could understand and do something so quickly Very efficient, yet comfortable. In my opinion, a very good technique. That was the first time I had done that, but it was kinda cool V. Mental Health Emergency Center: Outcome Measures

38 Received HRSA funding Network Development for electronic data interchange Expand video teleconferencing among users Return on Investment V. Mental Health Emergency Center: More steps ahead

39 QUESTIONS

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