Developers of the approach urge other communities to devise similar approaches, but funding is an issue
No problem has proven more vexing to ED leaders in recent years than the issue of boarding related to patients with mental health concerns. It is not unusual for these patients to be held in the ED for hours, if not days, before a psychiatric bed is found. This has the effect of running up the health care tab while bogging down throughput, and it leaves virtually no one satisfied.
The good news is that new models of care are emerging that show promise in not only alleviating chronic instances of boarding, but also connecting mental health patients with appropriate care in a much more cost-efficient way. Further, it’s clear that leaders in both the psychiatric and emergency medicine communities think the time is right to get both policy makers and regulators fully engaged on the issue.
Look for new solutions
Michael Gerardi, MD, FAAP, FACEP, the incoming president of the American College of Emergency Physicians (ACEP) and an attending physician in the Department of Emergency Medicine at Morristown Medical Center in Morristown, NJ, has made it clear that tackling the issue of psychiatric patient boarding in the ED is a top priority in the coming year. He signaled his intentions on this issue in October 2014 during ACEP’s scientific assembly meeting in Chicago, IL, referring to the fact that there were already communities showing the way forward on this issue. In particular, Gerardi points to “the Alameda model,” an approach developed over several years by Scott Zeller, MD, chief of psychiatric emergency services for the Alameda Health System in Oakland, CA.
“It was something that kept evolving over time. I kept adding parts that I thought made the most sense to help our population and also to improve things for EDs in the area,” says Zeller. “I didn’t realize how unique [the model] was until I became president of the American Association for Emergency Psychiatry from 2010 to 2012 and visited many different systems during that time.”
That’s when Zeller came to appreciate how significant the problem of boarding had become in EDs across the country, but he found it curious that the only solution anyone was talking about was building more psychiatric beds. “Psychiatry is the only medical emergency that seems to have a default treatment of hospitalization,” he says.
It made much more sense to Zeller to focus more attention on treating psychiatric patients at the front end because what he had found through his own model was that when these patients are quickly connected with the appropriate psychiatric care, the vast majority of them don’t require hospitalization. “That is when I [realized] that our system could really be a solution for a lot of people around the country,” observes Zeller.
There are a number of critical pieces to the system now in place in Alameda County, but one of the first steps in putting the model together involved ending the common practice of having police officers transport patients on an involuntary psychiatric hold, stipulated as “a 5150 hold” in California, to the hospital. “We created a system where police initiate the hold and then contact an EMS ambulance service. The police then transfer custody of the patient to the ambulance crew, and then the ambulance crew will do a field screening, looking only for medical stability issues,” explains Zeller. “Then, based on some criteria that we wrote together with the EMS leadership, the ambulance crew will decide if someone is medically stable, and if they are, they will bring the patient directly to our dedicated psychiatric ED at John George Psychiatric Hospital [in San Leandro, CA].”
With this process, roughly two-thirds of all the patients placed on psychiatric holds go directly to the dedicated psychiatric facility for evaluation and treatment. The other one-third of patients — whom the ambulance crews have determined need more medical clearance — will go to one of the county’s 11 EDs. For these patients, Zeller has established a streamlined process to facilitate transfer of the patients to the psychiatric facility as soon as they are medically cleared.
“The ED is just charged with making sure a patient is medically stable. As soon as [providers] feel comfortable that a person is medically stable enough to go to a psychiatric ED, they call us up and we immediately take the patient in transfer,” explains Zeller. “We don’t request any specific labs, there is no specific alcohol level [required], and it doesn’t make any difference what the patient’s insurance is. We are just glad that someone has taken a look at these patients and made sure there isn’t any medical compromise prior to sending them over to us.”
The receiving psychiatric physicians at John George have a triage form that they use when accepting patients from area EDs. “All the patients are transported, physician to physician, using EMTALA [Emergency Medical and Treatment Labor Act] guidelines,” explains Zeller. “We are considered a higher level of care for psychiatric cases than other EDs, so [emergency physicians] can make a transport from ED to ED, similar to going from a general ED to a trauma center.”
The way this typically works is the emergency physician will first call the receiving physician at John George to discuss the patient. “If they both agree that [a transfer to John George] is appropriate, which they do in the vast majority of cases, we will then take the patient immediately and will just have a short record of the discussion,” says Zeller.
Not all patients with mental health concerns are appropriate for transfer to John George Hospital, stresses Zeller. “We are a very high acuity site that is only set up for people who have what EMTALA would define as psychiatric emergencies — being imminently dangerous to themselves or others, or being so incapacitated by a psychiatric illness that they can’t care for themselves,” he explains.
Nonetheless, by eliminating all the hoops that emergency providers often have to jump through before they can transfer a patient to a psychiatric facility, the boarding of psychiatric patients has been all but eliminated in the county, says Zeller. “The only boarding in our county is the length of time it takes for emergency providers to arrange transport from their facility to our facility, and two-thirds of the patients aren’t even stopping at an ED anyway,” he explains. “We are pretty much trying to avoid any unnecessary use of medical EDs by psychiatric patients, but when they are in an ED, we try to get them out to an appropriate treatment site as quickly as possible.”
Consider alternative dispositions
Another key component of the model is the way John George Hospital manages psychiatric patients upon arrival. A triage nurse will first confirm that a patient is medically stable and conduct an initial evaluation. “Then the patient goes to a triage psychiatrist who is stationed right by the ambulance bay who will again assess medical stability and make a quick determination if some immediate medicines are needed prior to full evaluation,” explains Zeller.
At this point the patient will go to a large waiting-room type area where people can sit in chairs or lie down with a pillow or a blanket; people don’t have individual rooms because it is an outpatient service, explains Zeller. “People are worked with by psychiatrists, nurses, and social workers,” he says. “We’ve got 23 hours and 59 minutes maximum to get them better, and by that point we have to have made a decision that we need to hospitalize them, send them home, or somewhere else that is less restrictive than an ED.”
Currently, only 22% of the patients ultimately need to be hospitalized; the other 78% are able to go home or to an alternative situation such as a detox program, substance abuse program, crisis residential housing, or perhaps back to a board and care arrangement, notes Zeller. “There are many dispositions that are a lot more comfortable and not nearly as coercive a situation as being in a hospital,” he says.
Eliminate unnecessary workups
Mark Notash, MD, who became medical director of the ED at San Leandro Hospital in San Leandro, CA, in April of 2013, says the difference between the way psychiatric patients are managed in Alameda County and the other regions where he has worked is profound. “My experiences at other hospitals were so negative, with patients boarding for days or even up to a week,” he observes. “I have not experienced psychiatric boarding [here] except with pediatric patients who still need to have a bed at the psychiatric facility that we are allowed to send them to.”
Notash adds that his throughput data have shown that psychiatric patients are getting out of the ED faster, on average, than medical patients who require big medical workups. “That is not because of reduced lab requirements, but because of the ease with which these patients are accepted [by the ED emergency program at John George Hospital],” he explains.
However, Notash notes that the program could work even more effectively. For instance, he observes that many emergency physicians routinely order labs and blood work on psychiatric patients even though these steps are not required under the model in patients who are deemed medically stable. This happens in the ED at San Leandro Hospital as well as several of the other EDs in Alameda County, according to Notash. “Both the issue of [establishing a particular] alcohol level and the issue of getting all the labs and drug screens on these patients can add hours to the process,” he adds. “So once everyone is educated about [the model], it can become even better than it already is.”
Notash explains that he is also experiencing some problems with patients from outside the city of San Leandro presenting to his ED with a clear need for psychiatric hospitalization, but the police from the other jurisdiction have refused to place these patients on “a 5150 hold” because they also have a medical issue such as nausea, headache, or abdominal pain, he explains.
“What ends up happening in these cases is we need to call [the police in] those other places, and then sometimes they respond quickly, but other times it takes three hours for them to come [to San Leandro] and write a 5150 that, frankly, they should have written when they saw the patient and called the ambulance,” says Notash.
If physicians could issue 5150s on their own in Alameda County, that would resolve the problem, observes Notash, explaining that each county in California determines how it will handle 5150 holds. “I will be working with the county health officer, and if we can get that issue resolved by actually enabling physicians to issue the 5150, then it will be a non-issue, and I think the police will be happy,” he says. “If I can get that [issue resolved] then basically we will be having the shortest length of stay of any hospital in the country for adult psychiatric patients.”
Push for change in philosophy
To persuade other regions to consider developing Alameda model-style solutions of their own, Zeller recognizes that he would need data, so he designed a 30-day study during which researchers tracked all ED patients placed on involuntary mental health holds at five community hospitals in Alameda County. In particular, researchers noted the length of time between when patients were deemed stable enough for psychiatric disposition and when they were discharged to the regional psychiatric emergency service at John George Psychiatric Hospital.
The results, which were published in February 2014, showed that that in a sample of 144 patients, the average boarding time was one hour and 48 minutes, and only a quarter of these patients ultimately required inpatient psychiatric hospitalization. Researchers note that the boarding times were as much as 80% lower than comparable ED averages, and that the data showed that an appropriate psychiatric emergency service can stabilize more than 75% of psychiatric patients, significantly reducing the need for inpatient psychiatric beds.1
ACEP’s Gerardi certainly took notice of the data, and so did a number of states and communities around the country. “We have had visitors from all over the United States, and we have helped other parts of the country develop their own versions of the model,” observes Zeller. “We know of 12 different programs that are getting started that we have had some bit of participation in, and we seem to get new inquiries about it every day.”
However, a major stumbling block for many communities is coming up with a way to fund such a program. California’s Medicaid program has established a unique billing code for crisis stabilization which has been sufficient to cover the program costs of the Alameda model and several similar approaches that have cropped up around the state.
To get around this hurdle, advocates interested in establishing a similar approach in their own regions need to push for the same type of regulatory provisions or identify another source of funding, explains Zeller. Meanwhile, he and others in the psychiatric emergency field are advocating for coding changes on a national level.
“The key thing we have found is that not only can this billing code make it so these programs can be self-sufficient, but it also costs less than the cost of boarding, so actually creating this code saves money rather than creating a new demand for billing,” stresses Zeller. “Then, if you are able to avoid three out of four people being hospitalized, then you are actually saving thousands and thousands of dollars per patient there also.”
Making such a billing change is a “no brainer,” according to Zeller, but he notes that it requires a general shift in philosophy with the understanding that most psychiatric emergencies can be resolved in less than 24 hours. “Once you get away from the idea that any psychiatric emergency requires hospitalization, then everything else can follow from that.”
Open a dialogue
Kimberly Nordstrom, MD, JD, president of the American Association for Emergency Psychiatry and medical director of psychiatric emergency services at Denver Health in Denver, CO, is wholeheartedly in favor of a national revenue code similar to what California has established for crisis stabilization. “We are reimbursed at a very low level, and because of that, most systems can’t afford to have psych emergency services because we are providing a high level of care and getting reimbursed at a lower level,” she observes.
At Denver Health, there is a separate psychiatric emergency area that is adjacent to the medical ED, so psychiatrists are always available to see both patients from the ED as well as patients who present directly to psychiatric emergency services. Otherwise, Nordstrom explains that the service operates very similarly to the way the Alameda model does, with similar statistics. “We are able to discharge 76% of our patients, and we only see patients who are suicidal, homicidal, or what we call gravely disabled, meaning they can’t take care of themselves,” she explains.
However, without adequate reimbursement, the psychiatric emergency service barely squeaks by financially, notes Nordstrom. “Even though we are doing as high as an inpatient level of care, we are getting reimbursed on an outpatient level,” she observes. “So without re-looking at this whole revenue code issue, I don’t think there will be more of these kinds of services popping up, and we will continue to see a lot of patients boarding in EDs [around the country].”
Nordstrom says she is heartened by the fact that this issue is finally getting added recognition, and she is hopeful that improvements are on the way. “Boarding now is considered a national crisis … so it is no longer just psychiatrists arguing for [change], it is emergency physicians,” she notes. Nordstrom adds that other medical specialties and associations are also engaged on the issue, and the national government is paying attention as well. “We are going to start working on this together rather than the way we have been doing it up until now, which has been individually.”
Nordstrom’s advice to ED leaders who are struggling with a boarding problem is to start forming partnerships. “You are not going to know about options until you start talking as a community,” she stresses.
Notash agrees, suggesting that ED leaders open a dialogue with the medical directors at the psychiatric facilities in their communities. “Show them the research that Dr. Zeller has published with emergency physicians. If other counties could get this thing going, it would be very helpful because nobody has funding, and nobody has beds.”
- Zeller S, Calma N, Stone A. Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med 2014;15:1-6.
Michael Gerardi, MD, FAAP, FACEP, President, American College of Emergency Physicians, and Attending Physician, Department of Emergency Medicine, Morristown Medical Center, Morristown, NJ. E-mail: email@example.com.
Kimberly Nordstrom, MD, JD, President, American Association for Emergency Psychiatry, and Medical Director, Psychiatric Emergency Services, Denver Health, Denver, CO. E-mail: Nordstrom_kimberly@yahoo.com.
Mark Notash, Medical Director, Emergency Department, San Leandro Hospital, San Leandro, CA. E-mail: firstname.lastname@example.org.
Scott Zeller, MD, Chief, Psychiatric Emergency Services, Alameda Health System, Oakland, CA. E-mail: Vszellermd@gmail.com.