Patient-Focused Care Models Bridge Gaps in Psychiatric Care

Scott Zeller , MD

Vice President of Operations, Acute Psychiatry

Published July 14, 2022

Woman uses health in place with an ipad for behavioral healthcare.

For the past decade, behavioral health patients who go to the emergency department have waited. And waited. And waited. Sometimes they’ve waited as many as 30 hours or more before treatment even begins.

The truth is that in the vast majority of cases, this suffering is unnecessary. Research shows that 75% or more of severe psychiatric emergencies can be stabilized and discharged within 24 hours.

As leaders in healthcare, we must find more equitable and effective ways to care for this vulnerable population. We cannot expect community-based care to treat every crisis—many individuals with medical comorbidity or high acuity symptoms are beyond the capabilities of most community programs—so our emergency departments and acute care hospitals must be ready to care for patients experiencing a psychiatric emergency. Indeed, federal EMTALA laws define psychiatric emergencies as medical emergencies, so hospital emergency departments must be prepared to evaluate and treat these cases just as they would heart attacks or car accidents.

A Better Approach to Behavioral Healthcare

Health systems across the United States have demonstrated there is a better way when they take a patient-first approach. In some cases, patient volume calls for dedicated behavioral care delivery units. In others, a focused effort to train emergency department teams on mental health triage, de-escalation, and treatment is needed.

These approaches are already a reality at health systems across the United States and exemplify a Health In Place approach, where care delivery meets patients when, where, and how they need us. Sometimes this means virtual or hybrid care; at other times, in-person hospital care delivery is most effective.

Two examples I’d like to highlight have proven invaluable to hospitals and their communities across the nation.

Emergency Psychiatric Intervention (EPI) is an approach designed by physicians on the front lines of emergency medicine and acute psychiatry that more efficiently evaluates and treats behavioral health patients from the moment they enter the ED through discharge.
The EmPath (Emergency Psychiatric Assessment, Treatment, and Healing) Unit, which I’ve developed and helped launch at dozens of hospitals, delivers prompt, compassionate, high-quality care in a separate calming, homelike setting near the emergency departments on hospital campuses, with proven benefits for patients, hospitals, and communities.

The many benefits that hospitals have realized through these models are a testament to the importance of treating behavioral health patients in a targeted and appropriate way that best matches their needs while improving care delivery for all.

Common Spirit Health Finds Scalable Improvements

CommonSpirit Health is the largest Catholic health system and second-largest nonprofit hospital system in the U.S., operating more than 140 hospitals in 21 states. Like health systems across the country, CommonSpirit was experiencing a rapid increase in the number of behavioral health patients presenting to its ED. Perhaps its greatest challenge was lack of clinician training around mental health and substance abuse emergencies.

Senior leadership from CommonSpirit collaborated with Vituity beginning in 2021 to identify nine exemplary CommonSpirit EDs in Nevada and California that could not only succeed with EPI but also help to scale it across the organization. This resulted in numerous improvements across the nine participating hospitals within six months:

Door-to-medication times decreased from 158 to 44.5 minutes, and the percentage of patients receiving medications within an hour nearly doubled.
Use of first-generation antipsychotics decreased by 79% in favor of newer medications that are better tolerated, leading to fewer side effects without oversedation.
Length of stay for behavioral health patients dropped by an average of 21 minutes while volumes for this population remained constant.
34% of ED team members reported increased confidence in taking care of behavioral health patients and 82% reported a decrease in restraint use.

Billings Clinic Minimizes Need for Restraint

Billings Clinic serves a wide, highly rural catchment area that includes most of Montana, northern Wyoming, and the western Dakotas. Many of the clinic’s patients travel great distances for emergency behavioral healthcare. Before EmPath, these patients waited an average of eight hours in the ED. While that’s less than the national average, the clinic’s leadership still felt it was too long.

Billings Clinic opened adult and youth EmPath Units in spring 2018. As a result, ED length of stay for behavioral health patients dropped by more than five hours. Admissions decreased by half and recidivism plunged 50%. Previously, about 1 in 5 mental health and substance abuse patients were readmitted to the hospital within 30 days. After EmPath, this rate dropped to 1 in 8.

EmPath also proved to be an extremely safe setting for patients and staff. Among the first 4,000 who passed through the unit, only 0.2% required seclusion or restraint.

Collectively, these quality and efficiency improvements add up to $1.7 million in annual savings for insurers.

Mercy San Juan Medical Center Boosts Patient Satisfaction

Mercy San Juan Medical Center in Carmichael, California, runs an EmPath Unit in collaboration with Sacramento County. After the unit opened in September 2019, ED psychiatric boarding hours dropped by 77% in just one month. By December, ED length of stay averaged 7.6 hours. Presently, the overall length of stay is under five hours, which includes all time for medical evaluation and treatment, even for complicated cases like overdoses.

Mercy San Juan’s EmPath has proved to be exceptionally patient-friendly. In fiscal year 2021, the unit discharged 80% of patients home who would have been held for inpatient care in the past, while earning positive satisfaction ratings from 85% of those served, even though most of those patients initially arrived on an involuntary hold. Thanks to robust discharge planning, the number of patients returning to the ED declined 30%. Physical restraint use in this high-acuity population remains well below one percent of cases, while in standard emergency departments the same population might experience over 20% restraint use.

Patient-Focused Care Delivery

At the heart of better psychiatric care is a clinically proven and purposeful way to care for hospitals’ most challenging patient population. Through the use of models designed expressly for acute behavioral healthcare, health systems can increase accessibility to emergency psychiatrists for hospital-based provider teams, lower their overall wait and discharge times, and achieve superior clinical results.

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