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EDs struggle with mental health emergencies
Funding aims to help patients avoid long waits
In the emergency department (ED) at Palmetto Health-Richland, a 649-bed regional community teaching hospital in Columbia, SC, two waiting rooms have been converted into functional, secure units for patients with behavioral health problems who are waiting for transfer to a mental health treatment facility.
On any given day, an average of seven people with acute behavioral health emergencies remain in the ED because an appropriate treatment bed is not available, reports John Stewart, MD, director of emergency medicine and the hospital’s chief of staff.
"These patients are stabilized here; but when they remain here, they may not get the proper or appropriate medication or treatment," he says. "As a board-certified emergency physician, I have been trained to recognize and stabilize mental health emergencies, but I do not have the expertise or environment to provide ongoing treatment."
The problem is not unique to Richland or even to the state of South Carolina, says Stewart. Facing funding cutbacks, public and private mental health facilities have reduced the number of available inpatient treatment beds. As a result, people with mental health conditions must seek outpatient treatment in the community and, when they have complications, they seek care in the only available setting — the ED.
EDs across the country are struggling to provide appropriate care for these patients, and the problem has become particularly acute in South Carolina, notes Shelley McGeorge, program manager in the Office of the Medical Director of the South Carolina Department of Mental Health.
"In the past few years, there have been 250 public and private psychiatric beds that have been lost in this state," she explains. "Hospitals have been becoming more and more aware that they are not equipped to handle the onslaught of people having to wait for care. Hospitals, by nature, want to provide good-quality care, but were — especially in the past — not equipped to handle the care and needs of patients with behavioral health problems."
Each day, about 50-60 patients statewide seek psychiatric treatment in EDs, McGeorge estimates.
This past November, the state allocated $1.7 million in grants to local and regional community mental health centers to develop services that would help these patients receive appropriate care and avoid waiting in EDs.
"These grants originated with the awareness that more and more patients were coming to the emergency departments and that two things were happening: They had to wait a very long time to receive appropriate treatment, and other patients seeking medical treatment were being forced to wait because behavioral health patients were taking up so much of the providers’ time and resources," McGeorge says.
Collaborative efforts encouraged
To apply for the grants, mental health centers must, in most cases, demonstrate that they have collaborative arrangements in place with local hospitals, alcohol and drug treatment programs, and law enforcement and judicial authorities, she continues.
Last year, the department initiated a large training effort aimed at improving screening and treatment for patients with co-occurring disorders, a coexisting mental health condition, and substance addiction.
"We sponsored a large training event last year with representatives from hospitals, local alcohol and drug treatment facilities, mental health and law enforcement agencies," she says. "As they came together and talked about the problems in their local communities, then they each developed some sort of plan for what they would like to do to solve some of the issues that had to do with co-occurring problems and crisis problems, too."
Four of those initial collaborative efforts were funded through the state and helped pave the way for the $1.7 million in crisis stabilization grants that now are being distributed.
The programs being developed are across the board, from efforts to improve emergency mental health treatments available in hospital EDs, to efforts to improve outpatient mental health case management so that patients with behavioral health conditions do not experience the crisis situations that lead them to the EDs in the first place.
"Some of the funds are used to hire psychiatrists to serve in hospital emergency rooms, as well as providing crisis stabilization units at local hospitals — that might be in an annex or it might be trying to form a system so that bed space would be available at that actual hospital to free up some beds and make them short-term crisis stabilization beds," she explains. "It might also be to hire a social worker or counselor to come in and do on-site assessments of patients who are presenting to give better recommendations should a crisis happen."
The point is, representatives from the different stakeholder agencies are involved in designing programs that help alleviate the problems in their local areas, McGeorge says.
"A collaborative effort is just essential to solving this problem. We believe in that so strongly that we are in the process, statewide, of putting together a performance improvement team with representatives from all of the agencies to take a look at the best way to make crisis stabilization services better in our state."
Richland’s Stewart has been working for years to raise awareness about the problems EDs face in caring for patients with mental health conditions. Yet, he has frequently been the target of criticism from advocates for the mentally ill who believe he, and other emergency medical providers, want to restrict the freedom and civil rights of people with mental illness.
But the majority of mentally ill patients seen in his ED are not people who have regular access to psychiatric care or comprehensive health coverage, he says. Many do have co-occurring disorders.
"Most do not come in voluntarily asking for treatment," he explains. "They are brought in by police, paramedics, sometimes just members of the public."
Patients who don’t have regular access to treatment may be noncompliant with taking medications and end up having an acute exacerbation of their condition, he says.
"I look at it in the same way as other chronic medical conditions," Stewart says. "If someone with congestive heart failure stops taking their medication, they will have a complication and require emergency treatment. The same thing happens when someone with a mental illness doesn’t take their medication."
The problem is that people experiencing a psychotic episode or other mental health emergency cannot give consent for care or inpatient admission.
Physicians are legally authorized to pursue an involuntary commitment if they believe the person’s condition poses a threat to themselves or to other people.
In South Carolina, physicians can get a court order for a 72-hour involuntary commitment. With the bed shortage, however, patients who need such an admission often have nowhere to go, and EDs are not equipped to manage their conditions.
Although mental health advocates have accused him of wanting to commit people in order to move them more quickly out of the department, Stewart says he has a moral and ethical obligation to ensure that patients in crisis get appropriate treatment, which often means a short-term commitment.
Unlike many hospitals, Palmetto Richland does have an inpatient psychiatric unit, but those beds are often full, both with patients routinely admitted for care and transfers from other hospitals without such units.
Located across the street from a state mental hospital, Richland often sees patients whose conditions have improved enough to be discharged from long-term residential treatment, but do not have good access to follow-up care and remain in the general area, using the hospital as their last safety net.
Stewart has had ED staff knocked unconscious, assaulted and injured by patients who have become violent, and he has had to hire extra security and make the space adjustments to attempt to accommodate the influx of patients. But such measures are stopgap at best and don’t adequately address the problem.
"I want to be clear that I don’t mean to marginalize the mentally ill even more than already happens too frequently in our society," he says. "I want to be able to treat these patients in the same way I want to treat other patients. But we are only trained and equipped to stabilize emergency conditions until they can be appropriately treated in a specialized setting. When people require more advanced care, we simply aren’t equipped to handle them."
Since the crisis stabilization grants have been initiated, Palmetto Richland has seen a small, but significant reduction in the number of mental health patients experiencing extended stays in the ED and has access to psychiatrists who are able to perform rounds in the ED, providing emergency mental health consults and ensuring that the patients who are there receive the appropriate screening and medications.
Stewart says he is hopeful that the effort will both help improve care for people with behavioral health problems and alleviate the stresses on EDs, but says he thinks only time will tell.
The ultimate goal of the crisis stabilization grants is to address the needs of patients with behavioral health conditions in a number of areas — improving the ability of EDs to handle mental health emergencies, improving community case management so that patients with chronic conditions have fewer acute emergency episodes, and establishing alternative residential treatment options so that patients who have conditions that make it difficult to live independently have an alternative to long-term inpatient admission, says McGeorge.
Through a program known as ACT (Assertive Community Treatment) designated case management professionals, working with a team of other health specialists, would stay in contact with people known to be "frequent flyers" in EDs to ensure they are able to continue to receive the appropriate medication and follow-up treatment.
"You have a team of professionals, including a nurse, mental health professionals, psychiatrists, together involved in a team approach to track whether or not individual people are taking their medications or receiving services, getting appointments, and assist them in that process," McGeorge explains. "If they have crises, they should not have as many, and the ones they do have should be able to be better managed because we have been in contact with that person on a regular basis."
The new programs also are working to develop alternative residential treatment options for patients who may not require long-term inpatient care, but need some type of residential treatment.
"There are people who have needs, but don’t need the hospitalization — then we could reserve those beds to be used for more acute care or intermediate care beds," she says. "But, we need placements for long-term patients where their needs could be met, but that would not require hospitalization. One way to say it, is that we are trying to take care of the front door with the ACT teams beefing up crisis stabilization in the community. Then if someone presents in the ED, we’ll have better care for them there, but ultimately making sure there is appropriate care and long-term bed availability for those patients, working our way around the whole system."