Mental Health Boarding in Emergency Departments

National Solutions

& Lessons Learned From

the Washington State Experience

Moderator Dr. Stephen H. Anderson MD, FACEP

Panelists

• Michael Gerardi, MD, FAAP, FACEP, National President ACEP

• Ray Hsiao, MD, WSMA President Elect & Ass. Director

Children’s & Adolescent Psychiatric Residency U of WA

• Nathan Schlicher, MD, JD, FACEP, past Senator & WA ACEP

President Elect

• Jim Vollendroff, MPA, NCACII, CDP, Division Director, King

County Mental Health, Chemical Abuse and Dependency Services

Objectives • Why do we care?

• Washington State, “Feel My Pain”

• Problems Then,

Problems Now,

Problems In the Future…

Why Do We Care? Because They Come

2000- Estimates of 5.4% of ED Patients

2008- Estimates of up to 10% of ED Patients

2011- In several states up to

of Super Utilizers

have a primary or secondary Mental Health or Substance Abuse diagnosis at

discharge

Why Do We Care? Because They Stay…

Nationally of all ED’s Board Mental Health Patients

times longer then averaged boarded patients awaiting

admission

WA State Survey July, 2014:

44% of all ED’s surveyed had Mental Health Boarders

20% of those had been boarding over 72 hours

Maximum LOS in that survey, 6 days

Why Do We Care? Because it’s NOT the optimal environment to

languish in

Medical Screening Exams are necessary

Stress for Patients- 2008 DOH&HS Policy “creates an environment in which psychiatric patients slowly deteriorates”

One hospital in WA State Survey documented 50% of all psychiatric boarding patients

were at some point in physical restraints

Stress for Providers- ENA estimates > 90% of all ED RN’s have been physically or mentally assaulted

Burnout?

What’s Right With Washington State?

So… What’s Wrong With WA State?

In 2014 Report Card of Emergency Care in America Despite some improvements noted above, Washington continues to receive a failing grade for Access to Emergency Care. One major area of concern is the lack of resources and inpatient capacity for mental health

patients. The state ranks third worst in the nation for the number of psychiatric care beds (8.3 per 1,o00,000 people).*

* An IMPROVEMENT from 49th in 2009!

The Concept of Delta

50% of boarded patients in restraints

Over $2 Million dollars spent in 2012 in additional boarding resources

Psychiatric Bed Availability From 1955 to 2005

Inpatient beds in America decreased from

68O per 1 million

To

34 per 1 million

Lawmakers have voted eight times since 1998 to make it easier to commit residents. But despite those changes, the state over the past six years has cut 250 psychiatric beds and more than $100 million in programs designed to reduce detentions.

WA State Legislation

Modern Healthcare Hospitals in Washington state can't board psych patients in EDs, but where will they go?

Seattle Times, Dec. 5, 2013 ‘Boarding’ mentally ill becoming epidemic in state

Seattle Times, Aug, 2014

State Supreme Court rules psychiatric boarding unlawful

Battle in the Media Battle in the Courts

Timeline from the Courts • August 6th, 2014- State Supreme Court ruling

• Sept. 5th, 2014- 120 day “Stay of Execution”

• Dec. 26th, 2014- Ruling went into effect

•Now it’s not just wrong

Now it’s Illegal

What did we accomplish?

30 Years Ago The Solution To Mental Health

Issues In Washington State

• Funding $$$$

• Beds

• Staffing

• Infrastructure

2015 The Solutions To

Mental Health Boarding In America

• Funding $$$$$$$$$$$$$ • Beds

• Staffing

• Infrastructure

Funding • Cost of the average ED psychiatric complaint

across the board is $2,300 more then other

visits in the ED

• Cost to operate an inpatient psychiatric bed

$600-1,800/ day.

Funding

Funding

Funding

Funding It’s all about the money…

-August 15th, 2014- WA State Governor found $30 Million in

emergency health Care funds tied to ACA to jump start reform

(remember $100 Million in cuts over last 6 years).

-Creative sources for future legislative tax base

- “A penny saved is a penny earned”… Coordinating care of Super Utilizers identified through the ED’s

Minimizing unnecessary testing in Medical Screening Exams

Funding Prudent Stewards of the Health Care Dollar

• ACEP Clinical Policy on Psychiatric Boarding, Routine Testing: • 1. Patient management recommendations: What testing is necessary in order to determine medical stability in alert, cooperative

patients with normal vital signs, a non-contributory history and physical examination, and psychiatric symptoms?

• Level A recommendations. None specified.

• Level B recommendations. In adult ED patients with primary psychiatric complaints, diagnostic evaluation should be directed by the

history and physical examination. Routine laboratory testing of all patients is of very low yield and need not be performed as part of the ED assessment.

• Level C recommendations. None specified.

• 2. Patient management recommendations: Do the results of a urine drug screen for drugs of abuse affect management in alert,

cooperative patients with normal vital signs, a non- contributory history and physical examination, and a psychiatric complaint?

• Level A recommendations. None specified.

• Level B recommendations. None specified.

• Level C recommendations.

• 1. Routine urine toxicology screens for drugs of abuse in alert, awake, cooperative patients do not affect ED management and need

not be performed as part of the ED assessment.

• 2. Urine toxicology screens for drugs of abuse obtained

in the ED for the use of the receiving psychiatric facility or service should not delay patient evaluation or transfer.

Funding… The Hidden Cost

Beds Single Bed Certification

The Basis of the problem: WA State will no longer pay for Single Bed Certification unless new standards are met

New Standards: • Provision of appropriate and timely mental health treatment as defined by the WAC

• Implementation of written standards that assure a mental health professional (as defined by

WAC or RCW code) and licensed physician are available for consultation

• Creation of individualized mental health treatment plans

• Provision of daily contact with a mental health professional for each involuntarily detained

consumer

• Adoption of standards for the administration and monitoring of medication regimens

Beds Voluntary vs. Involuntary

WA State found 140 new INVOLUNTARY Commitment

beds on Dec. 26th…. Yippee!!!

Where Did They Find Them?

Converted VOLUNTARY Crisis Diversion beds…

Not so Yippee

Beds • ED or Elsewhere?

• Hospital protocols for moving patients

to Alternative beds for housing, with

Hospitalist/ Psychiatric

assumption of care

Beds

Beds- Re-enter WA State Courts

• Dec. 22nd, 2014- Seattle district Court rules illegal to

incarcerate patients in jail on mental health detainment

over 7 days without care.

• Governor immediately issued $8.8 million dollars to

reopen forensic psychiatric beds at states two largest

inpatient facilities

Personnel • Around 50,000 Psychiatrists in America in 2010, too

few to go around.

• Over the last 10 years, the trend is less & less

graduates of medical schools are entering the field.

• Over 50% of Psychiatrists in America are over 55 years

old.

Is it time for a new niche?

Personnel Lure Physicians to Your Community

• GME funding not only for primary care, but for all

of medicine (not increased in 15 years)

• Loan repayment programs- service to a

community including emergency call

• EMTALA Protection (Health Care Safety Net Enhancement Act of

2015, House Bill of Rep. Charlie Dent, R-PA)

Personnel Alternate/ Ancillary Team

• Physician Extenders- PA-C’s, ARNPs- Rounders in EDs

Staffing next day follow-up

• Non-medical counseling- Philadelphia “peer

specialists”

The Team Approach

Personnel ED Providers Education

• If 10% of my clients are psychiatric patients…

Do I need more CME in prolonged psychiatric care?

• ED Providers are the experts in the de-escalation of

“Agitated Delirium”… But then what?

Infrastructure Health Information Exchanges

WA State EDIE Emergency Department Information Exchange

PMP Prescription Monitoring Program

Emergency Department Information Exchange

EDIE Alert with Care Plan during MSE

Case Management

Registration to the cloud

WA EDIE ED Care Plan Standard

• Header Information/ Demographics – Date Plan First Created – Date Plan Last Updated

• Security Alert • ED Visits & Location in last 12 months

• Pain Contract and Scheduled Prescribing

PMP now PUSHED into EDIE

WA EDIE ED Care Plan Standard

• Primary Care Provider and Specialist • Past Medical and Surgical History • Substance Use and Abuse History

•Mental Health Conditions • Barriers to Care • Special Care Recommendations

WA State 7 Best Practices

Saved WA State Medicaid $33 Million in first year!

Infrastructure Telemedicine

All about dollars-

• Presently limited ability to bill Medicare for Telepsych, and < half the states

allow for Medicaid Telepsych billing.

• Build the pathways first over existing referral patterns

Infrastructure “No Need To Reinvent The Wheel”

Infrastructure Telepsych

• http://www.acep.org/telemedicine/

And What About The Kids???

Take Home Solutions- Funding • Tomorrow- Prudent Stewards of the Health Care Dollar- jettison unnecessary testing

• Next Month- Share Stats to avoid future cuts. Lobby now for next years Increases based on needs.

So start gathering you data!

• This Year-

Push for State & Federal funds/ Apply for CMS Grants

Guarantee Telemedicine Billing

Take Home Solutions- Beds • Tomorrow- Develop Protocols to move upstairs

Define what your hospital can do to be “Single Bed Certified”

• Next Month- Maximize Involuntary Capacity first, then backfill Voluntary beds

• This Year- Work toward solutions in Jails, including care there & follow-up after release

Take Home Solutions Personnel

• Tomorrow- Build out Education for ED Providers

• Next Month- Build your new TEAM- Redefine credentialing & Roles (i.e. PA-C, ARNP, etc.)

Recruit with incentives

• This Year-

New Residencies/ Loan Repayment/ EMTALA Protection

Take Home Solutions- Infrastructure

• Tomorrow- Map out Care Coordination- Identify most at risk, Assign & accept ownership

• Next Week- Start to work on Information Exchange- Within your system/ Across all systems

• This Year- “Under one roof”- Primary Care & Mental Health clinics in same building

Explore & Lobby for Telepsych. Build the infrastructure (including financials)

Mental Health Solutions

• Mental Health is a lifelong illness

• It isn’t “cured”, it’s managed

• Perfectly managed, it has relapses

• The goal is never to block access

• The goal needs to be to Coordinate Care

Mental Health Solutions For The ED & The Community

• Consider a paradigm shift, shifting the

upfront focus from the PCPs to the EDs

• THEN, open the back door to true resources.