Funding from the Mental Health Innovations grant offered by the Minnesota Department of Human Services provides a full-time case manager weekdays and an on-call case manager until 11 p.m. weekdays and Saturdays.
- Case managers meet with patients in the hospital ED when an emergency physician determines that the patient will not be admitted.
- Case managers create a plan with the person to see what he or she is willing to do and also explain the criteria to access services and programs.
- If the patient already is working with another agency in town, the case managers work to reconnect them and schedule necessary follow-up care.
A new grant is helping to provide a path toward stability for patients with mental and behavioral health issues who come to the ED. Often, many of these patients do not need to be admitted for medical treatment at all, but without the right help could end up floundering once back on the streets. Funding from the $260,000 Mental Health Innovations grant from the Minnesota Department of Human Services is working to close that loop.
In many situations, this oft-neglected population walks out of the ED without adequate resources or a path toward stability, explains Julie Wilson, MHP, director of adult community support programs at the Human Development Center (HDC) in Duluth, MN.
“We see it all the time. This is just an effort to help. If we can help 25% of the people who go into the ED with mental health issues and connect them, that’s just incredible. It’s a benefit to the person and to the community,” says Wilson.
Since its launch in July 2018, the HDC has responded to 25 “call outs,” meaning a case manager is sent to the ED. Each situation is different — many patients are homeless or at risk for homelessness, while some experience drug/alcohol addiction — but most have not been connected to services or have not followed through with services.
The HDC case managers, who moved into their new office building less than a year ago, are within walking distance to the hospitals involved with the grant program.
“The case managers utilize space in the emergency department when they are called to the hospital. We do not have designated space at the hospitals, but they try to give us as much privacy as they have available that day,” says Wilson.
As part of the process, HDC says it has a “memorandum of understanding” with each hospital. Part of that is HDC will not interfere with the hospital’s processes. In other words, if a person presented to the hospital ED because he or she felt there was an emergency that should be addressed at the hospital, the patient needs to be examined first.
“We don’t want the ED to not assess the person. It’s their patient the minute they walk in,” says Wilson. “Once that process is complete and determination has been made that the person will not be admitted, we get the call. We want them to get in the habit of calling us right away to say, ‘There’s someone who’s agreed to talk to you, can you come over?’ This frees the hospital personnel to work on other immediate issues.”
Wilson says her team has ongoing communication with the ED case managers.
“Sometimes our calls come from the case managers and sometimes from other hospital ED personnel depending on which hospital and time of day,” she says.
Wilson says her team from HDC has heard nothing but positive feedback since the program began. The HDC case managers hold monthly meetings with the lead hospital personnel for this grant (case manager, nurse supervisor, and clinical supervisor for the ED). At the meeting they discuss what is working and/or any barriers they are facing.
Accessing Community Services
Although hospital personnel often are aware of resources available to mental health patients, they may not understand the criteria to access those services.
“Everyone, and every program or service, has their own admission criteria, insurance criteria, and many other barriers to access that they just do not have the time to assess for each person. And it’s about follow-through,” says Wilson.
For example, take the case of a discharge order or recommendation for alcohol or drug treatment. For that to happen, the patient needs a Rule 25 chemical health assessment, apply for insurance, receive help finding a facility that will admit him or her, and then wait for a bed in that facility.
Even the HDC, which has been offering comprehensive behavioral healthcare services to the local population since 1938, acknowledges there are so many moving pieces to keep patients on track to get the right support. For instance, HDC performs targeted case management, which is a contracted service through the county and the state. In order to receive targeted case management, a patient must have a serious and persistent mental illness (SPMI), not just a serious mental illness (SMI).
“Unless you’ve worked in a community-based program for people with mental illness, such as HDC’s Community Support Program, you can’t possibly keep up or know everything that is out there and how to access. I believe the hospitals do a lot and they know a lot, but they are not out here working every step with the person to help them be successful,” says Wilson.
“They just can’t possibly do that. Otherwise, they would need to have their own Community Support Program, and there isn’t enough money in these programs for the hospitals to consider that,” she adds.
How EDCM Implementation Works
So how are the HDC case managers working to assist the ED personnel? The team, known as the EDCM, typically goes through this common process:
- patient presents to the ED with mental health and/or chemical health crisis/emergency;
- patient is medically examined and cleared, screened out for admission to inpatient hospital and/or mental health inpatient setting;
- ED contacts HDC on-call case manager;
- EDCM consults with ED staff regarding recommendations and proceeds to connect with the patient to develop a more detailed discharge plan (e.g., EDCM taking the person to a mental health crisis stabilization center).
The discharge plan and process with the patient include identification of immediate and longer-term needs. Core community support programs and other services are offered depending on the need. These may include:
- crisis stabilization center;
- peer support;
- outpatient therapy or counseling;
- addiction counseling and treatment;
- adult rehabilitative mental health services;
- case management;
- homeless services;
- benefits assistance;
- referrals to other services.
“This is about immediate follow-up, not setting up an appointment to see them next week. That doesn’t work,” says Wilson.
“They need immediate relief or help with ‘fill in the blank’ needs. And if we can help them immediately, they will likely trust us enough to seek help again or follow through with us on the discharge plan,” she says.
The HDC process also includes:
- establishing rapport with the patient through an informal interview and encouraging engagement to facilitate alternatives and/or discharge;
- assisting with identifying resources for appropriate level of care based on supports, current functioning, abilities barriers, and identifying alternatives as opposed to remaining at the ED or being admitted to inpatient setting;
- communicating and coordinating with family, support, and other providers;
- creating a plan for follow-up and assisting with follow-up interventions, making referrals, and linking to resources;
- when appropriate, transporting to alternative setting — shelter, crisis stabilization, family, treatment, etc.;
- facilitating the transition to appropriate outpatient mental health services;
- continuing EDCM until connected to and receiving the services that they need, at which time the HDC can close the loop.
How many expensive, unnecessary admissions could be avoided with more programs similar to what this grant is offering? In December 2015, the Minnesota Hospital Association published a mental health services whitepaper that discussed “a comprehensive and robust statewide mental and behavioral health system that serves all residents of Minnesota with appropriate, high-quality, accessible care.”1
The study sought options for mental health and behavioral patient care outside the hospital system. Among hospitals without inpatient psychiatric units, two participating hospitals had a total of 90 potentially avoidable days during the 45-day pilot. Of the behavioral health patients with potentially avoidable days, 83% of their stays were potentially avoidable, versus 17% that were unavoidable.
The hospitals noted the following reasons for potentially avoidable days:
- the need for an inpatient behavioral health bed accounted for nearly half of the potentially avoidable days;
- legal involvement accounted for about one-quarter of potentially avoidable days. In particular, criminal histories caused delays in placing patients in community-based settings;
- lack of access to community-based settings, though brief delays accounted for the rest.
Although it is only an 18-month grant, Wilson hopes this service, or some version of it, could be extended indefinitely.
“When people with mental health or chemical health issues reach the point of presenting to the ED, they need help now and not next week or next month when someone has time to follow up with them. If we can instill some hope at that time and physically show them that we can and will help them, we are then making a difference in their lives,” says Wilson.
Although the hospitals offer support, there are other options available in terms of funding and walk-in help for these clients.
“What do they need to get into this or that place, for example? We also want the word to get out that we offer walk-in assistance for anyone entering our door. We’re closing the loop so that they’re not out there floundering, only to end up back in the emergency room,” she adds.
1. Minnesota Hospital Association. Mental & Behavioral Health: Options and Opportunities for Minnesota. December 2015. Available at: https://bit.ly/2Nq8o9p.