Hopeful Solutions for Psychiatric Boarding

Hospital emergency rooms are frustrated by a bottleneck in achieving basic care for increasing numbers of patients presenting with behavioral health crises. Behavioral health specialist are often "on-call" and may take hours to arrive for an initial assessment and treatment planning visit. Then, patients may have to wait days for access to crisis stabilization services. EDs are not designed to provide prolonged episodes of care; "boarding" is the term use to describe the time spent by patients waiting for transfer. The problem of boarding persons with mental illness in community hospital emergency departments is nationwide.

This Bazelon Center report serves as a backgrounder on the issue.

Consider this example from Stanislaus County, California:

WARNING--this article uses stigmatizing language

One Problem:

"In the past five years, Emanuel Medical Center in Turlock has seen a dramatic increase in ER patients with a psychotic diagnosis, from 276 in 2007 to 681 in 2009. There were 591 visits last year.
The for-profit Doctors Medical Center in Modesto declined to release ER data on psychiatric visits, but said the caseload at its sister facility is telling. Last year, almost 4,300 people were treated at Doctors Behavioral Health Center and discharged, more than twice the number in 2007."

To rub salt in the wound, "Vartan said the behavioral center has operated at a loss since its parent company, Tenet Healthcare, purchased it from the county in 2007." [retrieved by rmcox on 25 may 2012 from published Sunday, May. 20, 2012]

One Opinion:

The Siamese-twin problem of boarding and poor behavioral health care has really escalated over the past 5 or 6 years. Reasons for this increase include:

1) economic problems for individuals and families increases stress-induced problems like anxiety and depression leading to increased suicidal behaviors and substance use problems overwhelm sufferer's coping skills;

2) economic problems for governments (primary payors for behavioral health emergency services) force cost-shifting and resource allocation choices. Local systems focus on immediate crisis services and reduce state-owned inpatient services;

3) healthcare policy "reforms" create service delivery systems built around early-20th century industrial concepts of "economic efficiency" and attempts to determine what works best (eg, evidence-based practices).

These three issue areas provide a number of critical incidents, like the one described in Medesto, CA.
Now, I'm not much of a market capitalist--too skeptical of the profit motive and the scarce resource concepts as motivators--but I am a big fan of communities solving their own problems. (I'll also go ahead and say that some resources should not be funded on a fee-for-service model. Healthcare is one of those resources.)

As government backs out of the innovation/solution side of the problem and into the accounting policy side local communities move into the vacated space. The excitement of change is the creative freedom that exists during chaotic times. This means that new forms of service delivery and new ways of thinking about patient care will rise from the compost of the old system.

One Answer:

One example of a locally created solution is presented in this example from Columbia SC scheduled to open in 2013:

"A renovated wing in the Palmetto Health Emergency Department hopes to increase quality of care for patients with mental illness." [cite: retrieved on 25 May 2012 by rmcox from  published 6:44 PM, May 14, 2012) will provide specialized care.

Because the needs of persons with acute mental illness are different from the needs of patients with acute physical complaints setting aside dedicated sections with dedicated staff if a good idea.

Behavioral health EDs are an innovation that is rapidly spreading from metropolitan areas to even modest sized cities. Services provided can include crisis stabilization, observation and assessment, and medication initiation. Most importantly, these services can be delivered away from the bright bustling atmosphere of the traditional emergency department.

There is hope for systemic change in how people with mental health crises can get help and access services. Not only are there new thoughts about how to do things, new coalitions of providers are talking about doing things in new ways. Exciting times!

Defining the field and chasing rabbits

Opportunity. Challenge. Developing a sense of humor. Being interesting. Creativity is a muscle that needs exercise. How much longer before I reach goal?...

While preparing for graduate school in the Fall (U of Memphis, counseling) I stepped up the development speed for a knowledge base, a library of information, about the field of emergency behavioral health. This project may be a gateway into a future career. One of the first questions I've had to struggle with is how to define the topic and the structures that will give the project it's shape.

The topic stretches into acute versus chronic treatments, victims of war and natural disaster, threats to individuals, families, organizations of all sizes. It is pretty clear that national economic crises are outside the scope, but what about the family struggling with developmental transitions? Should this be just about acute interventions and how to do them or should it include the all four phases from training and planning before the crisis through the post-vention and recovery phase?

Well, it should include "everything" that can be connected from a base definition. That much is clear. My personality would not let me do anything less.

There is the consideration of "crisis" vs "emergency" and the level of risk to health or property. But what is this thing, this construct, that so many people hang their hats on? Let's follow Flannery and Everly (2000) and start with the idea of psychological crisis.
A psychological crisis happens when a person or family is overwhelmed by some one, or series of multiple, stressful events that throw the person/family out of balance to the point that they cannot recover without assistance. Flannery and Everly refer to this phenomonon as the "crisis response" to the "critical incident" stressor.

This whole field is based on planning for, mitigating, responding to, and recovering from critical incidents. And, defining who, what, when, where, why and how crises happen. This blog will track rabbits and map the trails.

Mapping the Landscape: a Rationale to blog about Emergency Behavioral Health

Welcome to my latest blogging project. This blog will present my ideas about behavioral health crisis response as they develop. In the past I've used blogs to post news item and resources and to collect interesting items for presentation elsewhere; but not this time. Now I am collecting my thoughts after 13+ years of professional crisis response in preparation for a return to graduate school and the leap into the next phase of my career.

The field of emergency behavioral health is broad, making it very easy to get lost without a map. In this blog I will try to create such a map, a visualization or picture, of where the on the web the informational cities are located and what areas are ripe for development. The more I collect and organize my professional library the clearer the vision from the summit of the "big questions".

Over the years blogging has matured tremendously; my style and knowledge of blogging hasn't exactly kept up. To catch up I've surfed a little--according to Urban Dictionary "surf the web" is still a relevant phrase--and read that good writing is the key to getting and keeping readers. Marketing is how readers find what has been written.

So now I'm starting to lose focus from the topic/purpose of this post--staying focused is one of my "growing edges"--and getting caught playing with the language and not the idea. Cleanly stated: The purpose of this post is to talk a little about the challenges of maintaining a blog and what I hope to accomplish with this project.

I will have a job that allows me to travel (and collect commemorative stamp images like those issued through the Eastern National (EN) passport program and sought by the members of the National Park Travelers Club (NPTC)) and assist communities to serve their most vulnerable. All while living in serenity. Its a tall order. But, its time to direct my energies with my talents. For many years I've guided my career and personal choices with the mission "to give back to the community that gave so much to me" as I've adapted to compromise. Now I will take the hard steps to create my future. [time for a quick breather. that statement sets up so many challenges, I mean, opportunities.]

The most vulnerable include those who have used up all their resources to cope with life's challenges. A strong safety net is required for persons and families experiencing a behavioral health crisis or psychiatric emergency to return to normal functioning with as little disruption as necessary. This is the topic I will explore with this blog.

What have I accomplished tonight?

• defined my topic
• created a rationale post
• outlined my professional goal(s)
• reminded myself about the difficulty of practicing humility

What is left to accomplish?

•  outlining a structure for my posts
• linking to some guideline websites

1. Keep posts <250 words. (source)
2. Have interesting headlines. (source)
3. Use relevant keywords consistently and naturally to promote search engine optimization (SEO) and relevance for readers (should also force greater focus on topic organization). (source)

Lessons from previous blogging experiences:

1. post regularly with valuable content
2. this blog is not just a linkdump or collection of items. It is my job, as blogger, to connect the dots and show why the item is relevant.

Part structural guide, part lofty goal announcement, part focus statement: this post covers a lot of ground--and breaks most of the style guidelines just presented.... Thoughtful practice is important to increasing the subtly of our skills; reflection is required for thoughtful practice. Hopefully I can accomplish what this blog sets out to do...The Moon or Bust!