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!
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