EXECUTIVE SUMMARY

EDs see at-risk patients with behavioral health needs that are not met in the community. Hospitals might not offer the best resources for these patients. A solution is a collaboration between a health system and community psychiatric health organizations.

• A health system in Texas works with a county’s mental health services to place ED patients in psychiatric beds, as needed.

• Before the collaboration, behavioral health patients faced long holds in the ED, waiting for psychiatric care.

• Another solution involved developing a Mobile Crisis Outreach Team to assess behavioral health patients anytime.


Healthcare providers increasingly treat at-risk patients who present with unmet behavioral health needs, and it takes a village to solve this problem.

For example, a health system in North Texas has formed a collaboration with Collin County to address the behavioral health needs of ED patients who do not require inpatient acute care, but need outpatient mental health support or inpatient behavioral healthcare, says Susan Holsapple, LCSW, ACM-SW, regional director of comprehensive care management at Baylor Scott & White Health, North Texas East Region.

“Focusing on behavioral health is a growing trend,” Holsapple says. “People are more aware, but there is very little funding.”

In recent years, Baylor Scott & White’s ED has seen more patients with behavioral health needs, says Candace Hamilton, LMSW, ACM-SW, director of comprehensive care management at Baylor Scott & White Medical Center — Plano. “They faced long holds in the emergency department because they were unable to efficiently access the right level of care. There were a lot of hospital resources utilized to keep patients safe while on hold.”

The question hospital leadership asked was this: How could they help care managers address this burden and maintain patient safety? The county had some behavioral health resources and behavioral health inpatient beds in facilities that were not affiliated with Baylor Scott & White. But the demand for these services was greater than the availability, Holsapple says. For instance, one day in the ED, there were eight people waiting for a bed in an inpatient psychiatric facility.

“At one point, there was funding for only two psychiatric beds in the entire county,” Hamilton says. “All healthcare systems were holding patients at different times.”

ED patients sometimes would wait 24 to 72 hours for a bed that could help them weather a psychiatric crisis, Holsapple says. “It was unfortunate for them because it was delaying care they needed,” she adds. “My hospital is down the street from the county jail, and we were getting patients from the jail, as well, because it had been overloaded with individuals requiring psychiatric treatment. It was chaos all the time, and we weren’t caring for this vulnerable population the best we could.”

The confluence of greater need for behavioral resources and low funding led to the health system creating a potential solution that combines its resources, case management, and collaboration with local governmental and nongovernmental organizations.

“Our campuses do not have inpatient behavioral health resources, so we really wanted to be on the front end to ensure the population in our community got to the right level of care in the start,” Holsapple says.

The county was transitioning its behavioral health resources to a new model, giving the health system an opportunity to be involved on the front end.

“Once we heard there was going to be a transition, we did everything we could do to get in front of it,” Holsapple says. “We reached out and made contact with the county behavioral health authority.”

They also helped the local mental health authority align their work with acute care facilities in the area. Together, they could support this vulnerable population, Hamilton says.

One method was to improve communication between inpatient psychiatric facilities and hospitals. EDs needed to know how many inpatient psychiatric beds were available so they could use that information to help patients who presented to the ED with behavioral health needs, she explains.

“We needed some idea of the status, and there was not any communication to the hospitals involved,” Hamilton says. “Because of our feedback, they now send us an email with a daily bed list.”

This small change was transformative, resulting from Hamilton and Holsapple meeting with local behavioral health officials and building trust, she adds. “Susan and I helped develop these relationships, and when we bring up these ideas, they’re more receptive to it,” Hamilton says. “It’s been impactful.”

The hospital has developed additional partnerships in the community, building trust and working with the community behavioral health authority to ensure hospital staff can reach the right supervisor to facilitate a patient transfer from the ED to the psychiatric inpatient facility, Holsapple says.

With an understanding of how much behavioral health problems affected EDs and patients, the local psychiatric authority examined ways to expand their number of inpatient beds. They began to use their funding more efficiently, and apply for grants.

“They were able to look at their own funding and figure out a way to ensure there were always more than two beds,” Holsapple says. “The wait list doesn’t seem nearly as long. They seem to be moving people quicker.”

Another solution to the behavioral health crisis involves the use of a mobile health team, called the Mobile Crisis Outreach Team (MCOT). The outreach team performs behavioral health evaluations on site, and it travels to where patients are located, Hamilton explains.

Offering mental health support 24/7 was one of Hamilton and Holsapple’s goals. “Initially, they were operating with Monday through Friday business hours, and, obviously, the behavioral health world is never stopping, and our world never stops, so we asked that those services grow,” Hamilton says.

MCOT’s professionals assess individuals for a behavioral health crisis and determine whether a person is eligible for funding of their services, Holsapple says.

“We also started talking with other inpatient behavioral health facilities to see if we could get our patients the care they needed quickly, regardless of the funding,” she adds. “We’ve pursued various partnerships in the community with inpatient psychiatric facilities that are willing to screen our patients and decide whether they need behavioral healthcare.”

An additional intervention involved telehealth psychiatric services. Since the local Baylor Scott & White hospital lacked inpatient psychiatric services, there was a need for additional psychiatric care. Telehealth psychiatrists can fill that gap.

“It’s another tool we used to reduce the long and inappropriate holds in the emergency room,” Hamilton says. “We have patients evaluated by telehealth psychiatrists, who can recommend lower levels of care, keeping the patient safe, or initiating treatment and medication in our emergency room.”

These remote psychiatrists interact with the hospital’s providers and the local mental health authority. It is a cost-effective tool, Hamilton adds. “This is not perfect, but it is a resource, and it helps patients access care more timely.”

The hospital also hired an ED social worker to help facilitate transfers of patients with behavioral health needs. The social worker has a behavioral health background, Holsapple says.

These changes go a long way to fill the gap between the need for psychiatric services and the actual behavioral health services that are available in the community, Hamilton notes. The changes have worked because of the collaboration and trust-building between the hospital and local behavioral health entities.

“I serve on an advisory board for the mental health authority,” Hamilton says. “Our message is the time and resources it takes to be at the table is impactful to change.”