At Duke Raleigh Hospital, case managers in the emergency department lead interdisciplinary behavioral health rounds each day on all patients with psychiatric signs and symptoms.
During the rounds, the emergency department physicians and nurses discuss patients’ mental health issues and medical comorbidities. Psychiatrists who cover the emergency department participate whenever possible.
"The behavioral health rounds help the staff as well as the patients. The team can develop treatment plans for the behavioral issues that reduce acting out and help the staff identify triggers that may set the patients off," says Pat Kramer, Ed.S, CCM, CSW, NCC, director of case management at the hospital.
Case managers cover the emergency department 12 hours a day, seven days a week. Two are licensed clinical social workers, and one is a registered nurse. They assess all patients in the emergency department and create discharge plans for those who need it.
When patients with acute mental health needs are treated in the emergency department, case managers develop a treatment plan and set up an appointment with a mental health clinic or private psychiatry practice before the patients are discharged. "We don’t just refer patients with acute needs to resources in the community that can help them meet their needs; we make sure they have a follow-up provider before they leave," Kramer says. If patients don’t have acute needs, the case managers help them identify a provider. They educate patients with insurance on how to access their mental health benefits.
If the case managers think patients are going to need extra support to manage in the community, they set up an appointment with a provider who can see them immediately and call on the area’s Mobile Crisis Team or the Durham/Wake County Managed Care Organization, which manages Medicaid Behavioral Health Services, to send trained staff to the emergency department to escort patients to their appointment. The case managers have a close working relationship with the managed care organization for Medicaid mental health services and often collaborate on support for patients.
The case management staff developed a suicidal patient hand-off tool that the nurses use during shift change and when patients are moved from one unit to another, such as going from the emergency department to a unit on the floor or from the ICU to the nursing unit. For instance, the tool reminds the nurse to remove linens and plastic bags from the room.
"The hospital doesn’t have any dedicated psychiatric beds, so we are placing patients on a nursing unit. The hand-off tool reminds the nurses of the steps they need to take to secure the room and ensure patient safety," she says.