Responding to an identified need in the community, Children’s of Alabama in Birmingham created a Psychiatric Intake Response Center (PIRC) in 2018 to prioritize mental health care for youth. Mental healthcare professionals divide their time between assessing patients who present to the emergency department (ED) with mental health concerns and providing guidance to families who call the PIRC for help.
• PIRC staff constantly update a database of mental health providers and resources in the community so they can quickly connect families with the appropriate resources.
• Administrators credit PIRC staff with shortening the time behavioral health patients spend in the ED. Despite an increase in the volume of psychiatric patients this past year, lengths of stay were two hours shorter.
• Calls to the PIRC have increased, too, from 1,500 in 2018, to 2,200 calls in 2019. Further, the PIRC consulted on more than 3,600 ED patients last year.
Managing more patients with mental health concerns is an ongoing struggle for many emergency departments (EDs) in the United States. Pediatric EDs are no exception.
Many families have no idea where to turn for help with their child’s mental health issue. Thus, they present to an ED, even in cases where the child is not experiencing a psychiatric emergency. This can lead to ED congestion and long waits for care, both for mental health patients and those with common emergency care needs.
Looking for a new solution to this problem, leaders at Children’s of Alabama in Birmingham developed the Psychiatric Intake Response Center (PIRC) in 2018, a new organization embedded within the hospital’s ED.
PIRC staff members divide their time between assessing patients with mental health concerns who present to the ED and providing guidance to families who call the PIRC for help in finding the right mental healthcare for their children.
Cynthia Jones, MA, LPC-S, NCC, CRC, director of the PIRC, says the purpose of the center is to give people the ability to navigate the healthcare system.
“There are a lot of parents and caregivers in the community who simply don’t know where to go or who it is they need to see on behalf of their children with mental health issues. They call us, and we help them navigate and find an appropriate provider for them in the community,” she explains. “We joke that we are the Match.com of mental health. We find out what it is that the child needs, and match [him or her] with the appropriate provider.”
PIRC staff constantly updates a database of community-based mental health providers and resources.
“This database has grown significantly to the point where we now have 1,400 providers that we have been able to identify,” Jones reports. “These are psychiatrists, psychologists, counselors, social workers, marriage and family therapists, and other resources like support groups, long-term residential facilities, and substance use facilities.”
The database enables PIRC staff to quickly respond to the needs of families who call the PIRC with specific mental healthcare needs. By connecting these families with an appropriate mental health provider in the community, some ED visits likely are avoided.
Serve a Dual Purpose
Nonetheless, the ED seemed like the best fit for such a service. The PIRC is staffed with an array of licensed mental health professionals who can help provide assessments for patients who present to the ED with mental health concerns, explains Jesse “Tobias” Martinez, Jr., MD, a psychiatrist and medical director of the PIRC.
“When [PIRC staff members] are not assessing patients and families over the phone, they are able to see the patients in the ED,” he says. “Though we are not advertised as a crisis hotline, we, of course, do get calls from families that are in crisis when they have a child who may be at risk of harming themselves or others. We direct them to the ED. The same PIRC therapist [who spoke with family] is able to make that connection with the child in the ED to provide that continuity of care and handoff.”
PIRC therapists wear two hats. “They are answering the telephone for those families that are calling in looking for mental health resources, and they are also seeing patients,” Jones observes. “They have blocked time set aside for them to be on the phone and blocked time for when they are seeing patients in the ED.”
Mental health professionals who staff the PIRC are part of a larger psychiatric consult team operating in the ED.
“We have psychiatric nurse practitioners with us in the ED. We also have child adolescent psychiatric fellows who are doing their fellowship training, and then myself as the attending working with the team here evaluating patients,” Martinez notes. While the ED is open 24/7, the PIRC operates from 8 a.m. until 11 p.m. seven days a week. These are the hours when patients tend to check in for mental health complaints.
“We know that the majority of patients will come in during the later afternoon, after school ... so we always make sure we have appropriate staffing,” Martinez explains.
“Any patient who checks in to the ED with a psychiatric complaint in the middle of the night will be seen by the emergency medical team,” Martinez continues. “[The medical team] will staff the case with our child psychiatry fellow over the phone. Then, [the patient] will be seen the next morning by our PIRC team.”
As is the case with most EDs, patients who present with mental health concerns are seen by medical providers first. These providers will perform a brief medical exam to determine whether there are any medical concerns that require treatment.
In many EDs, there is no psychiatrist on site. Patients might be handed off to a therapist or a social worker, or they might be discharged with a list of mental health resources. However, in the ED at Children’s of Alabama, there are psychiatry team members ready to assess and evaluate patients.
“Once patients have been cleared by the medical team, psychiatry is involved to provide our consultation. Then, we will help with disposition options,” Martinez notes. “These could be discharge with outpatient resources, discharge to our crisis bridge clinic, or inpatient psychiatric admission.” The PIRC accelerates care to patients even in cases where patients are waiting in the ED for an open inpatient psychiatric bed.
“We have a behavioral health pod ... which consists of four rooms,” Martinez says. “We have the clinical services needed to provide clinical care for these patients.”
The hospital includes an inpatient psychiatric unit for patients requiring admission. When the unit is full, medical therapists from the PIRC will work to find a bed in another hospital for inpatient psychiatric care.
Martinez says there is an electronic bed board ED staff control, which enables PIRC workers to see where inpatient beds are available in the behavioral health units of public hospitals. In addition, PIRC staff maintain good communication with other hospitals in the community with inpatient beds. “We get phone calls on a daily basis to the point where the other hospitals are calling us and letting us know they have beds available if we have children who need inpatient psychiatric admissions,” Martinez says. “We have learned which hospitals and which doctors would prefer which types of patients. That is how we are able to keep our constant flow.”
There are risks associated with extended boarding periods, Martinez observes. For example, behavioral health patients can become more agitated, the likelihood of self-harm tends to increase, and the use of restraints increases as well. The extent to which PIRC staff can help limit long ED stays is positive.
Already, there is evidence the PIRC is making a difference. Jones reports that over the past year, PIRC staff have shortened the amount of time behavioral health patients spend in the ED by working more efficiently across patient care teams.
“Despite an increase in the volume of [psychiatric] patients this past year, there was a decrease in length of stay by 2.1 hours. That was from 7.4 hours in 2018 to 5.3 hours in 2019,” Jones explains.
Furthermore, it is clear that calls into the PIRC from the community are on the rise. In 2018, the new center received 1,500 calls. In 2019, the PIRC fielded 2,200 calls, which led to consultations on more than 3,600 ED patients.
A typical case might involve a young patient who has been referred to the ED for a psychiatric evaluation. An employee from the child’s school may have observed evidence of suicidal ideation or a behavioral disturbance. In other cases, there might be signs a child is thinking of self-harm because of bullying.
A medical provider starts by examining the child, looking for any signs of lesions, cuts, or any other wound. From there, the child is handed off to a PIRC therapist for a more in-depth assessment.
“The therapist will do risk stratification and safety planning for the family member who accompanies the patient to the ED. Then, the therapist will hand the patient off to me,” Martinez notes. “As the psychiatrist, I will review everything with the mental health therapist. Then, I will go into the room and summarize our plan, our treatment options, and what we are going to do.”
In most cases, such patients can be discharged if PIRC staff can ensure it is safe, there is appropriate follow-up, and therapy resources have been identified.
“Our surrounding schools are already aware they are going to receive discharge information from the ED saying that the child has been seen and is psychiatrically cleared to go back to school with follow-up instructions,” Martinez says.
Occasionally, the ED will see young patients who are acting out, are aggressive, or are even violent. Again, the medical team will look for any medical or organic reason for the behavior.
“For example, if it is a child with autism who is acting out, the medical team will make sure that the child is not acting out or becoming agitated because of any possible infection, constipation, or an issue like that,” Martinez explains. “Once the child is medically cleared, the parents are then told they will be speaking with a PIRC therapist who will do an assessment, make sure we have a safety plan, or an appropriate disposition plan. That could either be an inpatient admission or an outpatient plan.”
Martinez acknowledges mental health centers like the PIRC may be difficult for many hospitals to support because such services do not generate much revenue. However, he stresses Children’s of Alabama administrators recognized psychiatric patients tend to use many resources, especially when they are boarding in the ED.
Hospital leaders were convinced a center like the PIRC was a good idea when a community needs assessment revealed mental health should be prioritized for pediatric patients.
Fortunately, considerable funding for the PIRC has been provided through private entities. “There is an ongoing effort to let people know what we are doing and to seek out more opportunities for funding,” Jones shares.
“We have a PIRC advisory board with several members from the community. We meet quarterly to discuss the role of the PIRC, its mission, and other ways that we can improve,” Martinez says. “We also go out to community events and to the schools. That has really helped us develop relationships with the school system in our surrounding areas and with other mental health agencies.”
Martinez adds that he, Jones, and some PIRC therapists have attended community events to talk about mental health, provide education, and advocate for the PIRC. In addition, there are printed materials in the ED that describe what constitutes a psychiatric emergency.
The idea is to encourage families with pediatric mental health needs to call the PIRC for guidance. If families do not require emergency care, they can be connected to the appropriate care setting and not contribute to congestion in the ED. Martinez suggests there is evidence their outreach and education efforts are working.
“Even though across the nation the number of psychiatric patients coming to the ED is increasing ... we are still able to maintain good numbers with regard to shorter patient boarding times and appropriate dispositions,” he says. “We are seeing that patients who come to the ED are truly in a psychiatric emergency and may need to be admitted vs. [patients] who are discharged. The community is utilizing our PIRC line more frequently ... and getting connected with mental health resources in the community.”
Track Key Metrics
For those interested in developing a PIRC-like solution, make sure there is broad support for such an initiative within an institution, particularly the ED. “The ED is a big advocate for our services here,” Martinez says.
Further, be prepared to identify and track key metrics associated with any such initiative because stakeholders will want to know what the new center or service is accomplishing. For instance, Martinez notes the PIRC is keeping close tabs on declining boarding times and the move away from restraints and seclusion.
Follow-up data also may be critical to the long-term sustainability.
“When we provide mental health resources to callers and to those in the ED, we want to be able to call them back and ask whether they were able to be connected,” Jones says. “It is closing the loop and making sure they got from point A to point B. If they have not, then we are following up to make sure they get to that next level. Many times, there are barriers that we don’t even know about.”
Jones acknowledges there is no reimbursement for such follow-up calls, but they are crucial to staying connected with the community and, potentially, to securing ongoing financial support.