mental health boarding in emergency...
TRANSCRIPT
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.