Discharge Planning Advisor

Communication barriers, lack of coordination challenge care of behavioral health patients

Hospital to 'create windows' for front-line providers

It puts behavioral health patients at risk if the players coming to the table are not coordinating efforts to make the most efficient use of available resources, notes Mark Catalano, LCSW, manager of admissions at Seton Shoal Creek Hospital in Austin, TX.

Factors that typically challenge that process, he adds, include a lack of readily available psychiatric expertise and communication barriers between caregivers.

At Seton Shoal Creek Hospital and in the city of Austin as a whole, Catalano says, health care leaders are looking at a multi-faceted solution involving a mobile assessment team, telecommuting, standardization of tools and data tracking, and enhanced cooperation and communication between psychiatric hospitals and the emergency department (ED) clinicians who send them patients.

Part of the focus at Seton, he explains, is on "trying to create windows so that ED physicians and social workers know our capacity, what kind of patient is best for us, and which patients go on which unit." It's crucial not only to let them know what's available, Catalano points out, but to realize that each facility has its own way of describing patients.

Seton Shoal Creek uses a standardized risk assessment tool on every patient, including those in inpatient units, Catalano notes. "What we need from the ED [caregiver] is how high the risk is for that patient."

The number derived from the assessment determines whether and where the patient will be placed at the facility, he adds, but often the ED clinician is "not speaking the same language" as staff at the psychiatric facility during the assessment process.

In many cases, Catalano says, the patient in question has been to Seton Shoal Creek before. "We may have seen the patient 10 times, but he or she is new to ED staff and they describe the patient in a way that conflicts with our experience."

A behavioral health patient who presents at the ED "may be at the baseline for him or her," he adds, "but the ED [care provider] thinks the person is out of control." With accurate communication, Catalano says, "we may be able to say, 'Oh, that patient is just coming in to get a meal,' and give them suggestions on how to handle the person."

With such issues in mind, Austin's behavioral health leadership is working to standardize the assessment process across the city, Catalano says, "and see if we can agree on a core set of assessment tools, such as CIWA [Clinical Institute Withdrawal Assessment], CINA [Clinical Institute Narcotics Assessment], neither of which is used by any of the EDs, and a suicide or homicide/aggression assessment."

The implementation of such tools, he adds, will require education for ED nurses and social workers.

A pilot program started at Seton in July 2007, Catalano notes, focused on training social workers throughout the hospital network.

"We brought in all of our on-call social workers for the network — those who work all night — and educated them on our internal assessment forms so they could do our assessment for us," Catalano says.

When presented with data "on forms we recognized and used, with scores we would use internally," he adds, Seton personnel "know we can trust that [information]."

The payoff carries through to the utilization review piece of the process, Catalano notes, "when from the beginning we get good documentation."

Also under way, he says, is development of a software-based database that would allow "all the players — the ED, the emergency medical services, and the behavioral health hospitals — to share information," he says.

That information would be available, for example, when a patient presents to the ED or is en route to the hospital with an overdose, Catalano adds. With standardized data in one system accessible to all, he says, caregivers can check to see if and where appropriate beds are available for the patient.

Reminiscent of the television commercial about the efficiencies gained "when banks compete," Catalano says, Austin's two private psychiatric hospitals could quickly respond to an alert on a patient needing care with, for example, "We've got a level 12 bed on this unit, and it looks appropriate" because initial responders have used the standardized screening tool.

"What EDs want from us is for us to pull patients rather than them having to push them," he points out, "and the more we can trust the form and the language, the more we can do that."

ED not 'the enemy'

In the past, behavioral health providers tended to have an adversarial attitude toward the various EDs in town, Catalano notes. "We realized that we were looking at EDs as the enemy, feeling they were trying to dump patients or not give us all the information and [cases would be] different from what was presented on the phone."

The reality, however, is that the EDs "are our customers — the front line that finds patients for us," he says. "We've tried to [shift] our thinking and say, 'What do we need to put in their hands so they are better able to deal with the patient and can become our best sales force?'"

Seton Shoal Creek was on track to develop a mobile assessment team for behavioral health patients, Catalano notes, but it now looks as though the city of Austin — with matching in-kind contributions from the hospital networks — will take leadership of that project.

The idea, he says, is for caregivers to load information into a city-wide system while observing a patient onsite.

"We're looking at putting together teams in which a social worker and nurse would go out and look at the patient, with one psychiatrist assigned to oversee a certain number [of teams]," Catalano explains. The psychiatrist would be available to evaluate the individual in person if necessary or could use telecommunication to consult on the case.

Personnel for the mobile assessment team would be hired for the city under the auspices of the state Mental Health Mental Retardation (MHMR) department, he adds. The operation would be tied to the state psychiatric emergency services, Catalano says, "which are the 24-7 gateway to the state [behavioral health] hospital or other services."

At Houston's Memorial Hermann Hospital, where Seton staff made a site visit, a mobile assessment model is in place, he notes. "A medical director is paid to be available and is on call if the nurse or social worker on the team goes out and needs the physician piece."

The psychiatrist participation is "more to help smooth things out with the ED physician if the social worker is recommending something and the ED physician is not in agreement," Catalano says. "The trust factor is a barrier."

Houston is "a year or two ahead on the [telecommuting] curve," he adds. "It's another option for the mobile assessment team if they can't get to the facility across town in a timely fashion. Depending on the level of need, the social worker might do the initial assessment or the physician on call might do it."

In Austin, Catalano continues, there are plans to use mobile assessment in the same way. Returning to the example of a patient in the ED who has been there all night and into midmorning, he says, if such an individual could be interviewed via telemedicine by a psychiatrist or other behavioral health specialist familiar with his case, a lengthy stay and possible admission may be avoided.

"This is a way to reach out into the front line and add our level of expertise," Catalano says. "We see these kinds of patients day in and day out."

Call center role outlined

A behavioral health call center has a vital part to play in facilitating the treatment of a psychiatric patient who presents at the ED, notes Sue Altman, president of the Phoenix-based Call Center Consulting Network.

"The ED is really set up for medical patients and typically is already overcrowded," adds Altman, who offers strategic planning and positioning services for call centers. "Behavioral health issues are usually not dealt with very quickly in the ED. The last thing you need is somebody having a meltdown."

ED clinicians, of course, do a screening as quickly as possible to determine if there is a medical issue, she says. "If there is an overdose, obviously they would process that and, if necessary, admit the patient to a [nursing] floor."

However, a situation in which someone appears to be disoriented, with homicidal thoughts, auditory hallucinations or delusions, Altman says, "is usually not something an ED physician is comfortable assessing."

In such cases, she continues, ED staff would contact the call center, "which would get someone there to assess patients and get them on their way to the right destination for care, including [arranging for] some kind of transportation, often an ambulance."

That could mean mobilizing a social worker who is in a different part of the hospital, she says. "Case managers may be trained to do these quick assessments if need be."

If the facility is part of a system of hospitals and the necessary resources are not available at that location, Altman says, call center staff may call on one of the system's behavioral health professionals who may have to drive there quickly.

"They will do an assessment," she explains, "and typically call the call center back because it is arranging bed availability. Call center staff," Altman adds, "would know if the behavioral health facility or state hospital or psychiatric emergency service — which is like a big psychiatric ED — has a bed."

These psych EDs can hold a patient for 23 hours, but don't have inpatient facilities, she notes. "When patients present at the ED with bipolar [disease] or other conditions, in most cases, if they can be started on meds, within 23 hours — the length of time they can be held for observation — [staff] can have them under control and they can go home, with some follow-up."

Navigating the system

One of the problems in the behavioral health arena, Altman says, is that people who need the services don't know how to navigate the system. "Psychiatric or behavioral health services are not typically organized to serve an entire city or organization."

In medical care, physician offices are the "feeder system" for hospitals, she points out, but there appears to be a big disconnect between the psychiatric hospital and private practice psychiatrists or therapists.

Even people who have health benefits may not have much coverage in this area, Altman notes, and "there is a big movement for therapists not to accept insurance at all."

"[A condition] that may have been nipped in the bud if the patient had talked to someone at the primary care level may get really out of control before a family member [intervenes]," she adds. "If these people can't afford care or don't have resources or fear the stigma, they may lose their job and alienate from the family before it's obvious they need care badly."

The nation's uninsured population is another growing crisis, Altman says, which "hurts on both the medical and psychiatric side."

In two or three cities where Altman is working on call center strategies, she adds, private and governmental behavioral health providers are joining forces to look at solutions to the breakdown in services.

"What they recognize is they're all seeing the same patients, and end up just trading them," Altman points out. They may receive inpatient care, she says, "but once they return to their lives, if they can't get in to continue management with a psychiatrist, you're really just putting them right back in the same situation."

Efforts under way to centralize and track data, Altman says, are designed to answer questions such as, "Are [providers] seeing the same 100 patients or are there really 1,000 patients?"

"We know how many go through each of the [organizations] — they all have the counts — but until we look at the data level, we won't see that Jane Smith has visited all of us in the past month," she adds. "It could look like 1,000 people need services, but it could be the same 400 coming two or three times a month."

[Editor's note: Mark Catalano can be reached at mcatalano@seton.org. Sue Altman can be reached at sue.altman@3cn.org.]