In Raleigh, NC, hospitals, law enforcement, the mental health system, and organizations that serve the mentally ill are collaborating to provide care and smooth transitions between levels of care for people with mental health and substance abuse issues.
North Carolina has a shortage of psychiatric hospital beds and a critical shortage of psychiatrists in many areas of the state, says Pat Kramer, Ed.S, CCM, CSW, NCC, director of case management at Duke Raleigh Hospital, a 186-bed community hospital.
"In 2010, there were 60% fewer beds in state psychiatric hospitals than in 2001, when mental health care reform began in North Carolina. This means that there were many patients on the waiting list for a psychiatric hospital bed, and they were waiting in emergency departments like ours," she says.
From January to June 2010, 86% of all patients who were waiting for a bed in a state psychiatric hospital waited in a hospital emergency room or crisis unit for an average of 2.6 days, according to a report by the Wake County chapter of the National Alliance for Mental Illness.
"The lack of psychiatric beds is a problem all over the United States. This means patients with mental health and substance abuse issues are staying in the acute care hospital longer. We’re measuring the time patients stay in the emergency department in days, not hours," Kramer says.
Patients with mental health and substance abuse issues are over-consumers of emergency department services, Kramer points out. "A lot of the patients we see in our emergency department over and over have a mental health issue, and many times, they have medical issues as well," she says.
Improving access to care
In 2007, when the state psychiatric hospital in Wake County announced plans to close, three acute care hospitals — none of which has a psychiatric unit — partnered with a local private psychiatric hospital, a mental health center, and Wake County Human Services and formed the Wake County Crisis Cooperative to respond to the crisis in treatment options for the mentally ill.
Since then, the coalition has grown to 16 members, including representatives from the Durham/Wake County Managed Care Organization, which manages Medicaid behavioral health services, the Wake County sheriff’s office, the Raleigh police department, Wake County Magistrate’s Court, Wake County Emergency Medical Services’ Advance Practice Paramedics, the state psychiatric hospital for the region, the Wake County chapter of the National Alliance for Mental Illness, a disability specialist from the SSI/SSDI Outreach, Access and Recovery (SOAR) program, and a large community agency serving the uninsured.
Participants met regularly and brainstormed ways to improve access to care for the mentally ill. For instance, the partnership standardized the mental illness and substance abuse assessment tool so the patient’s condition and needs would be clear across all entities.
"Some facilities are still using their own assessment tool, but the tool we developed has raised awareness of what the psychiatric hospitals need to know about the patients. Education about the tool and the criteria has reduced frustration among the case managers, the nursing staff, and the providers," she says.
Another achievement was developing and getting state approval for standardized transfer guidelines for medical clearance for mental health and substance abuse patients being transferred to state-operated mental health facilities. In the past, each facility had its own guidelines, requirements for laboratory values, and definitions of medical stability.
With the standardized transfer guidelines, the case managers aren’t being told different things when they call different hospitals trying to place patients. "This was a tremendous achievement because it reduces frustration with facility-specific guidelines and saves time for our case managers because everybody is now on the same page," she says.
Defining high acuity
The group created a definition of a high-acuity patient to assist psychiatric facilities in prioritizing admissions. "Patients who are homicidal or suicidal don’t need to be waiting in an emergency department. Now patients who meet the definition of high acuity are moved up on waiting lists, and the hospitals understand that these patients are taking priority over patients they are trying to place," Kramer says.
The organization created a uniform process for involuntary commitment. Wake County Crisis Cooperative partnered with a private entity to provide mobile crisis services in the community. As a result of the meetings, a psychiatric hospital contracted with an acute care hospital for internal medicine consultations so it could take patients with higher medical acuity. The organization developed a rotation schedule for acute care hospitals when the crisis center goes on diversion.
Since the initiative began, Duke Raleigh Hospital has increased its psychiatric coverage in the emergency department. More patients are being transferred straight from the emergency department to an inpatient psychiatric facility, rather than spending time in an inpatient bed, she says. "There are fewer psychiatric beds available, but it’s still easier to get patients out because of the standardized transfer guidelines and assessment," Kramer adds. But at the same time, difficult-to-place patients, particularly elderly psychiatric patients, are staying longer in the hospital before they are transferred, she says.
The Wake County Crisis Cooperative continues to meet monthly. "The whole community has joined together to improve treatment and transitions of people with mental illness," Kramer says.