Call centers play vital role in ED psychiatric care

Quick deployment of clinicians possible

A behavioral health call center has an important role to play in the treatment of a psychiatric patient who presents at the ED, says 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."

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: Sue Altman can be reached at sue.altman@3cn.org.]