Last year OPEN MINDS covered the issue of psychiatric boarding – when a patient in psychiatric emergency remains in a hospital emergency department while waiting for admission to a psychiatric facility – from a number of perspectives:
- Washington Ban On Psychiatric ER Boarding May Have Longer Legs
- Another Perspective On Psychiatric Boarding
- You Have To Take Something Out, To Put Something In
- Hospital Strategies For Addressing Psychiatric Boarding
- Psych Boarding Top Priority For Emergency Physicians – But What Does That Mean?
In response, Verletta Saxon, Ph.D., Crisis Assistant Director at Centerstone wrote the below article offering a solution – community alternatives may provide essential emergency crisis services, designed to collaborate with community partners, reduce cost, and eliminate psychiatric boarding.
Centerstone, a not-for-profit community-based behavioral healthcare agency, opened the doors of the Centerstone Crisis Center in July, 2013 and took on the substantial task of psychiatric boarding in community EDs. Historically, individuals in crisis received emergency behavioral health assessments at local EDs, which included an expensive ED charge and long waits without treatment. Since that time, Centerstone has worked intensely with our local hospital system and partnered with other community organizations, to improve care for clients who have behavioral health emergencies by reducing usage of EDs for non-medical behavioral health crisis.
At the inauguration of the Crisis Center, we had three goals: (1) change the culture in our community by providing behavioral health emergency assessments at the Crisis Center instead of the ED, (2) deliver immediate crisis treatment services to clients for 3-5 days in our 8-bed stabilization unit, and (3) provide up to 45 days of follow-up services upon discharge from the stabilization unit. We were successful in our endeavor to change our community culture by marketing the service to clients and providers in the community. By the end of our first fiscal year, we provided 19% of our emergency behavioral health assessments at the Crisis Center.
At the start of development year 2, Centerstone collaborated with several community partners to create a system that would divert individuals from the ED, improve the quality of services provided, reduce cost and client wait time, and convert wait time to treatment time. During this process we created 3 models and have begun implementation:
- Model 1: ED Entry
- Model 2: Crisis Center Entry
- Model 3: Telemedicine
Model 1: ED Entry
Clients who arrive at the ED in need of an emergency assessment see a behavioral health Emergency Therapist for an assessment. Clients who qualify for voluntary hospitalization are discharged and transported to the Centerstone Crisis Center for additional treatment services while they wait for placement at a psychiatric unit.
Model 2: Crisis Center Entry
Clients who walk through the doors of the Crisis Center receive an emergency assessment at the Crisis Center. If the client qualifies for voluntary placement at a psychiatric unit, a phlebotomist draws labs. While the client waits for lab work processing, they receive additional behavioral health services atypically received at the hospital ED. After labs are processed, the client is transported to the hospital for medical clearance and placement at a psychiatric unit.
Model 3: Telemedicine
Clients who present at the Crisis Center for an emergency assessment and qualify for voluntary hospitalization remain at the Crisis Center until they are placed at a psychiatric facility. Labs are drawn at the Crisis Center and couriered for processing; telemedicine video conferencing is used to complete medical clearance. The client is completely diverted from the ED.
Implementing the models above create capacity for other health emergencies in the ED, increase revenue in the ED, decrease client wait time, increase treatment services provided to clients, reduce cost, and decrease medically unnecessary services.
During this process we identified a few barriers to implementation:
- Emergency Medical Treatment and Labor Act (EMTALA)
- While EMTALA allows hospitals to transfer clients to a psychiatric unit for treatment services, it does not allow for the transfer of clients to appropriate community resources that would provide immediate treatment.
- Having an effective regional transportation system that allows safe access to emergency crisis services at a lower cost is valuable to the client, but often unfunded and therefore out of reach for clients serviced in a behavioral health emergency.
- A large percentage of clients served at the hospital ED are often transported by a local ambulance service, which is expensive and restricts patients with medical issues from receiving treatment.
- Providing safe and cost effective services to clients in a behavioral health crisis outside of an ED would reduce the overall cost of emergency services for this population of individuals, but funding for innovative ideas is presently unavailable.
The aforementioned models improve quality of care, reduce cost, provide immediate treatment, and offer viable community solutions to psychiatric boarding.