Mental illness and acute care

For a long time, behavioral health patients have been marginalized in the nation’s health care system. This has been due in part to lack of insurance coverage and the low priority placed on caring for these patients. Closure of many inpatient psychiatric units, reduction in outpatient services and limited community resources have led to a perfect storm in the delivery of mental health services for psychiatric patients with acute behavioral health issues.

This perfect storm has led to patients with mental health problems frequenting emergency departments across the country, translating into a significant spike in the number of psychiatric patients seen. What's more, a large number of patients presenting to emergency departments with non–mental health complaints screen in for psychiatric diagnoses. 

The consequences of this increased volume are amplified by limited training and experience among emergency nurses and physicians, inappropriate emergency facilities for these types of patients, and reliance on restraints and medications to control rather than to treat behavior in the emergency setting.

Behavioral health providers have difficulty locating appropriate facilities for patients who are seen in the ED and need an inpatient admission. Mental health patients in EDs not only wait longer to be seen than others and have longer stays in the ED, but they also are boarded for longer times than other patients, because, when they need to be admitted, there often are no available beds.

A recent study surveying ED directors across the country found that 10 percent report that patients wait more than one week for an inpatient psychiatric bed in their community. A study citing ED directors in California found that 23 percent of mental health patients are sent home without a psychiatric consultation. This delay in locating beds is greater for pediatric cases or patients with developmental disabilities who need hospitalization.

Unlike medical patients in the ED waiting for beds, mental health patients tend to wait without any therapeutic interventions, consultation from specialty services or initiation of appropriate medications.

Asking why

Trustees and other leaders dedicated to providing quality health care in their community may want to consider how to improve and coordinate acute mental health services for their health care systems.

Why, after all, are mental health patients treated differently from other patients? When a trauma, cardiac or stroke patient presents to the ED, a team of appropriately trained and experienced providers come immediately to provide the finest level of service. For these patients, treatment is initiated in the ED, and specialty consultations and inpatient beds are obtained quickly.

Is this difference in care due to lack of resources, understanding, money or expertise?

It is not due to a lack of insurance coverage — at least not as much now as in the past — because we know that in many states the Medicaid population has expanded and chronic mentally ill patients are now covered.

It is not a lack of understanding, because we know there are many organizations that are able and willing to assist health care institutions in providing optimal mental health care education to providers. It is not a lack of expertise, because we know there are at least 140 centers in the country that are dedicated to psychiatric emergency services, and there is a specialty association dedicated to increasing clinical knowledge and expertise.

It should not be for a lack of coordination of services, because we know that in some counties in the country, organizations are able to work together to provide the right service in the right place — not only for the chronically mentally ill in acute crisis but also for the homeless population and those who need substance use treatment. One such collaboration results in the amazing services provided in Baxter County, Texas.

Rather, it is simply the responsibility of health care organizations to find alternatives for the appropriate care of these patients, including inpatient, outpatient and community services.   

Renewed focus

The first step in improving services for those with an acute behavioral problem is a needs determination and a gap analysis. This analysis should include a determination of the number of patients who wait in the ED for an inpatient bed and the length of time they stay; the number of patients who need to be transferred to another facility; and the adverse and iatrogenic effects of boarding patients in the ED. A cataloging of available mental health resources in the health care system, hospital and community is valuable in identifying alternative resources that may be available for these patients.

Collaboration with accountable care organizations, primary care clinics and multispecialty groups to integrate medical and psychiatric care, as well as reduce inpatient admission rates and length of stay for mental health patients could provide the financial incentive to focus on these services.

One solution is a crisis stabilization unit where patients spend from 23 to 72 hours. Its focus should be on resolving patients’ acute crisis, stabilizing their medications and integrating their care. Sinai Health System in Chicago saw such a need and become the first hospital in its area to add a unit like this.

Care in the ED also needs to be carefully examined. The care of behavioral health patients can begin early in the process with steps such as initiating assessment and treatment at triage.

Health care institutions that coordinate the delivery of services with nontraditional partners will not only meet the needs of their community but do so at a lower overall cost. Collaborations with law enforcement, corrections agencies, community mental health services, substance use treatment providers, detox services, homeless care agencies and advocates for mental health services such as the National Association for Mental Illness can provide the basis for enhanced coordination of services.

This renewed focus on acute care of the mentally ill is not only a financially sound venture but can enhance commitment to the community.

Leslie S. Zun, M.D. (zunl@sinai.org), is system chairman of emergency medicine in the Sinai Health System in Chicago and president of the American Association for Emergency Psychiatry.