Borderline personality disorder. Schizophrenia. Psychotic tendencies. Suicidal behaviors. Typically found in the caseload of an inpatient psychiatric facility, these conditions have become prevalent in another area of the U.S. healthcare system: the acute-care hospital emergency department.
In 2006, an Institute of Medicine report concluded hospital emergency rooms are overwhelmed, citing increases in lengths of stay for patients seeking care, crowding of existing ER space and boarding of patients who need an inpatient bed as the reasons.
And a recent study published online in the Annals of Emergency Medicine shows that psychiatric patients spent more than 11 hours in the ER, on average, when they sought care. According to the recent findings, the need for hospitalization, use of restraints and completing diagnostic imaging led to more time after a patient was assessed, while the presence of alcohol on toxicology screening caused delays earlier in ER stay.
“Basically, the ER has gone from an emergency room to a place where all of society's problems show up,” says Dr. Nicholas Vasquez, an emergency services physician at St. Joseph's Hospital and Medical Center in Phoenix, who did not speak on behalf of the hospital. “And one of those is mental health issues.”
A noisy, chaotic place isn't the appropriate setting for patients who require stability and quiet, says Vasquez, past president of the Arizona College of Emergency Physicians. As he explains, the 60-bed emergency department where he works expands and contracts throughout the day and includes an average of three to four psychiatric patients daily.
Vasquez says patients “run the gamut from baseline schizophrenia and homeless, or you have worse combinations—renal failure (patient) who needs dialysis and is schizophrenic,” he says. “They are the ones who die early; you can't presume they will take care of themselves. You can't presume they will take their medication.”
The cause of additional psych patients in emergency departments is multifaceted. To begin, the National Association of State Mental Health Program Directors reports that nearly 4,000 state psychiatric hospital beds have been eliminated since 2010, a year when 46 states faced budget shortfalls.
“What we're seeing is most state mental health hospitals operating are focused on the forensic patients and long-term-care patients, not the acute-care patients,” says Mark Covall, president and CEO of the National Association of Psychiatric Health Systems, which represents behavioral healthcare providers that own or manage more than 700 psychiatric hospitals, general hospital psychiatric and addiction treatment units and behavioral healthcare divisions, residential treatment facilities, youth services organizations and outpatient networks.
Forensic patients are those who have some legal proceeding that keeps them in a hospital rather than jail.
“So that system has gone away, and they are seeking care in the community,” Covall says. “And because there are not as many resources for them, they end up going to the only place that does have 24/7 care, and that's the emergency department.”
Often, psychiatric patients are homeless or live in unstable housing situations and return repeatedly to the ER. In the past, these patients would be sent to the state mental health system, but that doesn't happen as much anymore, as states face budget problems and tighten their behavioral health resources. The public health system has contracted more quickly in the past decade and has been hit especially hard in the past five years, Covall says.
“In healthcare, we're trying to shift resources,” he says. “In the mental health arena, we had the public mental health system and the private system—they used to operate individually,” he adds. “But as the public system contracted, it put more pressure on the private system, which shows itself in the ED. The EDs are the safety net. That's where it's visible—that's where you can see what's happening.”
This is why Covall says there is a great need for better coordination between the public and private mental healthcare systems, and also an expansion of community-based services.
“In doing so, it's not necessarily more money, but running them more efficiently,” he says.
Psychiatric patients in hospital ERs have been a “chronic problem” in the state of Maine for the past 10 to 12 years, says Dennis King, CEO of Spring Harbor Hospital, an 88-bed not-for-profit psychiatric facility in Westbrook. King also serves as president and CEO of Maine Mental Health Partners, a not-for-profit organization focused on building an integrated system for mental health providers across 11 counties in the state.
King says about 5% of MaineCare (the state Medicaid program) participants account for about 55% of the costs in hospital ERs. And at Spring Harbor, about 25 patients have more than five stays a year in the facility and are among the highest users of hospital's emergency services.
To address this issue, Spring Harbor joined with Maine's Health and Human Services Department and Shalom House—a Portland-based organization that provides community-based services for adults with mental illnesses—to establish the Assertive Community Treatment Integrating Outpatient Networks, or ACTION program, which began in 2007.
Funded by Maine's HHS department and MaineCare, the program relies on Spring Harbor for the therapists, psychiatrists and the nursing function for a specific population and on Shalom House for the residential needs.
“It's a combined treatment team so residential staff know the therapeutic goals for each client,” says Ed Blanchard, clinical director at Shalom House. “Even though it's two organizations, it's one clinical team,” he says, adding that the organizers wanted to develop a program that would help patients gain skills and also avoid ER visits and hospitalizations.
Local hospitals are aware of patients in the ACTION program—which tops out at 25 individuals—and they refer patients in the ER either to be hospitalized at Spring Harbor, or to Shalom House, which provides either a group home or independent living (with access to staff and medicine). The program relies on an Assertive Community Treatment, or ACT, team, which includes a psychiatrist, nurses and case managers.
Dr. James Wolak is director of psychiatric emergency services at Maine Medical Center in Portland, the largest hospital in the state. The hospital and Maine Mental Health Partners are part of the MaineHealth system. Three years ago, the hospital renovated its emergency department, which has a six-room psychiatric unit. Maine Medical has about 5,000 encounters with psychiatric patients annually, of whom about 27% are admitted to a psychiatric hospital.
Wolak says the hospital used to admit more patients to psychiatric facilities, but has been able to decrease the number partly through more sophisticated assessments. Meanwhile, patients waiting to be admitted to an inpatient psychiatric hospital often have to wait longer in the emergency department—sometimes as long as 24 hours—until a bed becomes available.
“Another reason why we've been able to decrease our admission rate is that we have these resources in the community that we can use,” Wolak says, adding that Maine Medical has had a working relationship with the ACTION program from the start. He says the relationship goes beyond a referral and a discharge because it involves a coordinated treatment plan. Representatives from the hospital have regular meetings with ACTION team members, which allows them to provide better treatment for the patients.
“It was innovative thinking, reaching out across systems and getting different players in the overall mental healthcare delivery system to communicate and work with each other, rather than operate in their own little bubbles,” he says. “And to also approach patient care—to view the overall patient-care plan for each patient, rather than dealing with the here and now—which is the ED mentality.”