Years of deep cuts to mental health care services have left ill-equipped hospital emergency departments struggling to care for untreated patients. Three organizations confronted the problem head-on by integrating behavioral health into primary and specialty care, screening and supporting vulnerable families, and developing expansive partnerships with other organizations.
The hectic, stressful nature of the typical emergency department makes it a less-than-ideal setting for mental health care. Nevertheless, hospital EDs have become a major component of the nation’s de facto behavioral health system.
The reasons: years of funding cuts to public mental health organizations and the resulting loss of thousands of inpatient beds at state and county facilities, coupled with increased demand for services. Mental illness and substance abuse account for 4 percent of ED visits, or nearly 5.5 million visits a year.
The increased pressure on already overburdened EDs results in distracted staff, bed shortages and, too often, a worsening of mental health patients’ conditions, asserts the American College of Emergency Physicians.
Adds American Hospital Association President and CEO Rich Umbdenstock, “The other unfortunate thing is [that] if it’s not the hospital, it’s the local jail or prison system, and that’s equally problematic.”
To address the problem, many hospitals are embarking on strategies to increase access to mental health screening and outpatient services, to improve behavioral health care within the ED, and to connect patients with medical and social services in the community.
The growth of value-based payment and accountable care makes these efforts even more imperative. “As the world moves to that type of payment system, keeping a population healthy means keeping them healthy physically, mentally and, frankly, socially,” Umbdenstock says.
An integrated approach is critical because mental illnesses can manifest themselves physically, and physical illnesses can trigger mental health problems, says Miriam Phalen, a member of the Children’s Hospital at Montefiore cabinet, which is a small group of board members, donors and others who help to raise funds and advocate on behalf of the organization. “It’s important for hospitals to get on board and say, ‘We’re going to treat every individual holistically, not piecemeal.’”
Here’s a look at a handful of innovative approaches hospitals are taking to improve care and access for patients with mental health concerns.
Montefiore: Integrating Psychiatry Into Primary Care
At New York’s Montefiore Health System, requests by primary care physicians for help in treating patients with behavioral health issues sparked an initiative a year ago to begin embedding social workers and psychiatrists in each of its 23 primary care sites.
All primary care clinics now have a social worker, and half have a psychiatrist. The remaining psychiatrist slots are expected to be filled by year’s end, says Brian Wong, M.D., Montefiore Medical Group’s director of adult behavioral services.
The new care model includes universal depression screening for patients at the primary care clinics at least once annually, but ideally at each visit, Wong says. The self-administered screening starts with a two-question tool. Patients who screen positive then get a nine-question tool. Primary care physicians refer patients who again score positive to the social worker, who, in some cases, is able to see the patient in the same visit. After a full psychosocial evaluation of the patient, the social worker consults with the psychiatrist, and they decide whether the patient needs a referral to the psychiatrist.
Most patients receive therapy from the social worker. The primary care physician handles prescriptions for common, less-severe mental health problems. The psychiatrists spend about half their time consulting with the social workers and primary care physicians and the other half working directly with patients with the most severe mental illnesses.
“What it’s done is improve access for patients to either be seen by a psychiatrist or have a psychiatrist’s input [so that] the primary care physicians can prescribe,” Wong says.
Asif Ansari, M.D., medical director at Montefiore Medical Group–Grand Concourse clinic in the Bronx, says that before the program began there, primary care physicians weren’t asking patients about their mental health often enough. “Now that we have a system approach to this, there is that net where these screens are being managed and looked at by a social worker on-site,” he says. “No one slips through the cracks.
As Montefiore moves more toward population health, the collaboration between primary care and mental health clinicians will be crucial in managing patients with chronic diseases complicated by behavioral health issues. “Mental health and physical health are intertwined,” Wong says. “When [patients are] suffering from depression, we know they are not able to take care of their diabetes or their hypertension and take their medications and make dietary modifications or exercise.”
To illustrate the collaborative care model’s impact, Ansari tells the story of a new patient who’d recently moved back to New York following his divorce. He told Ansari that before his move he had gone to a New Jersey ED because he felt like hurting himself and was referred to a psychiatrist but never went. The patient later almost committed suicide.
In addition to providing medical care, Ansari was able to connect the man that day with a social worker to get the ball rolling on his mental health care. “He came in because his diabetes was out of control, but if you don’t ask, you don’t know.”
Montefiore offers a similar approach for children and their parents through its Healthy Steps for Young Children program. The initiative reaches 16,000 families at four Montefiore Medical Group outpatient clinics in the Bronx. It will be available in all of its primary care clinics by the end of 2016.
Healthy Steps is focused on helping vulnerable parents and their children from birth to age 5. Families are screened regularly for child development, social emotional development, maternal depression and adverse childhood experiences. When a child or a parent is identified as being at risk or having a behavioral health issue, that person receives care on-site, which helps to dispel any stigma the patient might feel, Children’s Hospital cabinet member Phalen says.
The immediacy of care is invaluable, she adds, using the hypothetical case of a mother with newly diagnosed postpartum depression as an example. “It’s not like walking out of the office and having time to think, ‘I’m fine. I’m just overwhelmed,’ instead of saying, ‘Maybe this really is something. I’m struggling through my day and having difficulty concentrating.’”
The Healthy Steps approach is particularly effective because new parents often are more receptive to help, Phalen says. The team can help them to understand what is developmentally appropriate for their children at different ages. Parents learn how to handle such routine but often stress-inducing matters as how to get an infant to sleep through the night and how to deal with toddler tantrums.
This is especially important for parents who suffered abuse as children and don’t have positive experiences to draw on. The social workers and psychiatrists are able to help these parents cope with their experiences and “become healthy so they’re better parents,” she says.
Early intervention for parents and children at risk of or experiencing behavioral health issues prevents problems from developing or worsening. “If it’s not treated, it doesn’t go away by itself,” Phalen says.
Atlantic: Building a Full Continuum of Behavioral Health
Over the years, Atlantic Health System in New Jersey has built a continuum of behavioral health care that reaches from inpatient mental health and ED services to outpatient therapy and even partial hospitalization and residential care. Now it’s working to fold behavioral health into its hospital-owned, community-based practices.
Atlantic has embedded psychologists in many departments, such as diabetes, pain management, oncology, cardiology and bariatrics.
“There are psychiatric components to all of the chronic diseases that need to be addressed,” says Linda Reed, R.N., vice president of integrative and behavioral medicine and chief information officer. “If you can embed those kinds of services up front, you can facilitate coping throughout the whole care process and you don’t wind up with hospitalizations.”
Integrating behavioral health into those departments removes the stigma associated with mental health care and improves patient compliance with treatment, says Lori Ann Rizzuto, director of behavioral and integrative health services. For example, behavioral health is integrated into the diabetes curriculum. “You have the nutritionist, the diabetes educator and the psychologist. It doesn’t seem to be odd in any way because they’re part of the team.”
The health system has geropsychiatric units at three of its hospitals. Services are designed to address the specific difficulties faced by older adults, including higher incidence of depression and isolation. “Most of the time people come in and they’re treated for their medical problems, and their behavioral or psychological problems are put on the back burner,” Reed says. “This is the other way around.”
In its EDs, Atlantic has made accommodations to better serve patients with mental health conditions. Communitywide shortages of inpatient psychiatric units mean that patients might wait days for a bed. Atlantic hospitals have space set aside in their EDs for behavioral health patients to prevent overstimulation that can worsen their conditions. There, patients are started on active treatment plans so time isn’t wasted while they wait for an inpatient psych bed, Rizzuto explains.
Atlantic also is beginning to integrate behavioral health clinicians into some of its employed practices outside the hospital. “One of the things we’re struggling with as a health system is the expense of doing that,” Reed says. “What does it cost? Who funds it? Do you get enough benefit on the other end for the funding? At some point will the payers fund it?”
The system owns a 650-physician multispecialty practice, and one challenge is to figure out where the need for behavioral health care is the greatest, Reed says. It might be primary care, diabetes care or cardiology.
Atlantic is starting by focusing on practices that share the hospital’s culture and participate in risk contracts. “We’re finding the people who we think are really charged up and understand what we’re doing,” Rizzuto says. “They understand the difference between what the costs are up front and what the value is downstream.”
Behavioral Health Network: Linking all the Providers
The 2010 closure of a state mental health hospital caused alarm in the St. Louis-area health care community over the increased demand it would place on an already overburdened system. To come up with solutions to the problem, local hospitals and community mental health centers collaborated to create the Behavioral Health Network of Greater St. Louis.
The organization developed the Hospital-Community Linkages Project, which facilitates referrals from hospitals to community mental health centers and improves care coordination between them. The project is funded primarily by the state and also by an annual fee paid by participating hospitals. It targets patients who are uninsured or on traditional Medicaid, who aren’t already linked with a service provider, and who have a serious mental illness.
On the inpatient side, each of the 11 participating hospitals and seven community mental health centers has a dedicated liaison. When a hospital is discharging a patient from its inpatient psychiatric unit, the liaisons participate in discharge planning, schedule an outpatient appointment and transfer medical information, says Wendy Orson, the network’s CEO. The initiative is expected to generate 700 or more referrals from inpatient units this year.
In the project’s ED component, emergency department staff or the hospital liaison calls Behavioral Health Response, a nonprofit mental health crisis response provider with 24/7 mobile outreach services. If the mobile outreach team is available, it goes to the ED to meet the patient and schedule an outpatient appointment. If the patient leaves before the team gets there, it follows up within 24 hours. The program generates about 540 referrals from EDs each year, Orson says.
Implementation of the ED project at Barnes-Jewish Hospital required a culture change, says Robert Poirier, M.D., chief of clinical operations and emergency services and a Behavioral Health Network board member. ED clinicians needed training to adopt the process of screening patients for eligibility and referring them early so that the response team is able to arrive before the patient leaves.
The network attributes a 47 percent reduction in ED visits and a 57 percent drop in inpatient days to the project. Only 18 percent of clients are readmitted into the hospital in the six months following admission to a CMHC. A study of the project’s Medicaid patients showed an annual cost-reduction of about $5,450 per patient for the health care system.
“Even though it may not be run by the same organization, [the project] still could be considered an accountable care organization because everybody is accountable to each other,” Poirier says. “If there are problems on the outpatient side, the inpatient side is eventually going to notice because the patient comes in and needs to be admitted. On the inpatient side, if we don’t connect to the outpatient side, we treat them and a week later, when they’re off their meds again, they’re bouncing back and costing more.”
Geri Aston is a freelance writer in Chicago.
Growing Need, Declining Capacity
- 19% - Nearly 19 percent of American adults had some sort of mental health condition, and 4 percent had a serious mental health problem in 2012.
- 27% - Nearly half of Americans will develop a mental illness and 27 percent will have a substance abuse disorder sometime during their lifetimes.
- 4,000 - The United States has 4,000 mental health professional shortage areas.
- 29% - Twenty-nine percent of people with a medical disorder have a comorbid mental health condition.
- 5 billion - States cut $5 billion from mental health services from 2009 to 2012.
- 4,500 - The country lost at least 4,500 public psychiatric hospital beds, nearly 10 percent of the supply, from 2009 to 2012.
- 1/3 - One-third of community general hospitals have inpatient psychiatric units.
- 2 million - More than 2 million discharges from community hospitals were for a primary diagnosis of mental illness or substance abuse disorder in 2009.
- 9 in 10 - Nearly nine in 10 emergency physicians responding to a May 2014 poll reported that psychiatric patients were being held in their EDs.
Seven Recommendations from the AHA
A report from the American Hospital Association Task Force on Behavioral Health offers hospital leaders several recommendations on strategies they can undertake to address mental health needs in their communities. They include:
Struggling with overuse of the emergency department, Lee Memorial has found a way to manage nonemergency behavioral health and substance abuse patients. Read "Connecting ED patients to Outpatient Services".
- Ensure that community health assessments include specific attention to behavioral illness.
- Review and evaluate the organization’s behavioral plan in light of identified community needs, patient needs and available community resources.
- Use a comprehensive financial and operational assessment to evaluate the benefits and value of behavioral health services to all operational components of the hospital.
- Encourage and participate in developing a communitywide plan for people with behavioral health disorders and in coordinating community agencies that address behavioral health needs.
- Work with community agencies and with state and local governments to ensure that patients are treated in the most appropriate setting so that the hospital’s backstop role is appropriately limited.
- Create a formal plan that clearly defines the hospital’s role and its established relationships for behavioral health with other providers, practitioners, and government and community agencies.
- Clearly communicate to public and private payers the costs required to care for behavioral health patients and the cost to society of not treating those patients.