To be sure, there is a lot of buzz about using community paramedicine programs to help manage the behavioral health (BH)-related demand on busy EDs, but hospital administrators and EMS service providers considering such an approach must be fully aware of all issues involved with taking such an approach.
“You have to have policies and protocols, and you have to worry about liability when you send paramedics by themselves to try and work with mental health patients,” explains Michael Colman, MPA, NR-P, the vice president of EMS Advanced Practice at GHS. That’s one of the reasons why Grady Memorial Hospital’s EMS service came up with the idea for handling many of these calls through mobile mental health units that include both a paramedic and a mental health social worker, an approach that has been in operation since Grady developed its Upstream Crisis Intervention program five years ago.
The name of the program reflects an evolution in the care of mental health patients at Grady.
“Years ago, a lot of mental health patients would just come into the ED, get a mental health evaluation, and then go upstairs to where they were managed,” Colman notes. “Then, Grady moved those [mental healthcare] resources down to the ED so that now when a patient comes to the ED, there is a special place for mental health patients where there is a psychiatrist and social workers.”
Given the high demand for BH care, Grady then decided to provide such services “further upstream” by moving them out into the field through the mobile mental health units, which are deployed by EMS, Colman explains. Now, EMS endeavors to work within this program to prevent behavioral health issues encountered in the field from escalating into crises requiring a hospital visit.
“This program is 100% reactive. Something has to happen in order for patients to call 911, and then we respond,” Colman notes. “The problem with these types of situations is that the patient has [often] decompensated or has moved out of their normal state into some sort of crisis, and then once the paramedic/social worker team gets there, it is very difficult to reverse that.”
Consequently, when responding to 911 calls, mental health unit teams educate patients, family members, and caregivers about recognizing the typical cycle of a mental health condition.
“You can kind of tell that it goes from step A to B and to C, and then at some point there is a 911 call, and all these resources show up, and the patient goes to the hospital,” Colman explains.
With this knowledge, patients or caregivers are urged to call for assistance earlier, when less aggressive intervention will be needed.
“The next time when [a mental health condition] progresses from A to B to C, they can call [the Georgia Crisis and Access Line (GCAL)] and get us out there quicker so we can head the problem off at the pass,” Colman notes.
With this approach, patients are directed to the mental health unit teams through a different route.
“They are not coming from 911; they are coming from GCAL, which is a little bit easier to manage,” Colman adds.
Make Follow-up Calls
In addition to activating this alternate route earlier in an emerging behavioral health crisis, the mental health unit teams also make follow-up calls to patients to make sure they are OK and have the resources they need to manage their condition.
If they haven’t filled their prescriptions, the paramedics will retrieve them for the patients, and make sure they understand how to take them properly, Colman explains. The teams also distribute medication organizers and planners to keep patients on track, and they even offer a solution for patients who are illiterate.
“Sometimes, we have to go see a patient four or five times before they will tell us that they can’t read,” Colman notes. “Then, we take all of their prescriptions and go back to Grady, and we get the pharmacist to reprint the labels so that they have a rooster for the morning, a sun for the afternoon, and a moon for the night on the prescription bottle.”
Colman notes that a lot of what the mental health unit teams do is mitigate the challenges these patients face, and stay in contact to make sure patients are compliant with their medical instructions.
“A lot of these patients have cell phones, so we will send them a text, asking if everything is good, and checking to make sure they have all of their medicines,” he says.
Colman notes that filling a prescription is not so easy for a patient who is on the brink of homelessness and doesn’t have any financial resources.
“We will kind of bridge that gap for them,” he says. “We will call the doctor, and we will get the prescription called in, and we will go pick it up for them.” This is where the mobile health unit teams are really effective, Colman stresses. “We have tons of patients who will be calling 10, 15, or 20 times a month, and then they don’t ever call again. We just keep going to see them twice a month.”