The number of new psychiatric patients arriving at Mission Health’s six emergency departments each month shot up 31% between 2014 and 2016, from 419 to 547.

Due to a severe shortage of psychiatric inpatient beds in the community, the system’s flagship, Mission Hospital in Asheville, N.C., had to hold many of these patients inside the ED, with the average number of boarded patients at any one time soaring from 15 to 60 during that two-year period. One patient who was particularly difficult to place lived continuously in the ED for 19 months, until he was recently discharged.

The increase in the number of these sometimes-disruptive psychiatric boarding patients was hurting quality of care for all ED patients and putting both patients and staff at risk of injury, Mission Health CEO Dr. Ronald Paulus recently wrote.

An increase in mentally ill patients arriving in hospital EDs is a pressing problem across the country, said Dr. Renee Hsia, a professor of emergency medicine and health policy at the University of California at San Francisco. A study she co-authored in Health Affairs last year found a 55% jump nationally in ED visits related to mental health from 2002 to 2011, from 4.4 million to 6.8 million.

Meanwhile, the number of inpatient psychiatric beds available nationally to serve these patients plummeted nearly 80% from the 1970s to 2010, from about 500,000 to 114,000. In North Carolina, nearly 90% of inpatient beds have closed over the past decade.

The surge in psychiatric patients “is unsafe for everyone in the ED, and not just physically,” Hsia said. She and her colleagues frequently must call police to restrain violent patients before they can chemically sedate them. Those with concurrent substance abuse issues are the most disruptive.

“Because of the crowded conditions and limited resources, even patients with time-sensitive physical illnesses get poorer care,” she said.

To address the problem, Mission Hospital established four special holding areas in the ED for psychiatric patients, with the entire psychiatric staff rounding daily on all those patients to provide active treatment, said Dr. Richard Zenn, Mission Hospital’s medical director for behavioral health. Two are near the hospital’s psychiatric unit, making it easier to share expert staffers.

Patients with mental health issues are moved to the behavioral holding areas—which function like psychiatric units though they aren’t licensed as such—once they’re cleared on medical issues. “It’s safer and more appropriate for them, and then they don’t interfere with the care delivered to other patients,” Zenn said.

The hospital recently hired its first full-time emergency department psychiatrist. Mission Health also created a behavioral emergency response team that can be summoned by any staffer at any time. It’s getting an average of 30 calls a month.

In addition, the system also started providing telepsychiatry coverage to evaluate ED patients at its five regional hospitals.

Beyond that, Mission Hospital partnered with other healthcare organizations and the state to open a comprehensive mental health center across the street that’s open 24/7 and provides a wide range of crisis, outpatient and pharmacy services.

It’s an urgent-care center for mental health, said Sonya Greck, Mission Health’s senior vice president in charge of behavioral health and safety net services. “People can walk in off the street with no conditions attached,” she explained. “They can sit in a living room and talk with peer specialists who have been through this themselves.”

Creating psychiatric holding areas in the ED and hiring an emergency department psychiatrist have led to faster discharge of patients with mental health issues from the ED and improved overall patient throughput, Zenn said. The closely watched “left-without-being-seen” rate for ED patients in March declined to 0.27%, from the mid-single digits. That shows wait times and satisfaction improved for all types of patients.

The opening of the outpatient mental health center across the street from Mission Hospital has started to bear fruit in reducing certain types of behavioral health patients coming to the ED, Zenn added.

Assaults on staff members have fallen, though they still average about 15 per quarter, Paulus wrote.

“All these strategies are chipping away at the problem,” said Zenn, whose system is considering adding new psychiatric beds to its current supply of 33 adult beds. “But we still have a lot of (psychiatric) patients in the ED.”

A major problem in North Carolina, and around the country, is that hospitals don’t get paid for providing behavioral healthcare to patients during psychiatric boarding stays, giving them little incentive to improve care and reduce these patients' reliance on the ED. Zenn and his colleagues are working to encourage the North Carolina Medicaid program to develop service definitions and pay for this care.

In addition, since many of these patients are uninsured, Zenn wants to see North Carolina expand Medicaid coverage to low-income adults, which the state’s new Democratic governor and several Republican lawmakers have proposed. “That would help with accessing outpatient services and prevent patients from having to come to the ED in the first place,” he said.

Still, hospitals can help solve the psychiatric boarding problem themselves, even in a challenging reimbursement environment, Hsia said. They could do that by collaborating more closely with each other, opening more inpatient psychiatric beds, and launching dedicated psychiatric emergency services.

But first they have to recognize their common interest in better serving these patients, rather than receiving and quickly discharging them from their EDs, or passing the problem off to safety net hospitals like hers.

“When hospitals realize that not having these services can impact their bottom line because (ED) beds are taken up by nonpaying patients, they may understand it makes sense to figure out a solution,” Hsia said. “Because those patients are still coming.”

Modern Healthcare