Behavioral Health in The Emergency Department

Jill RachBeisel, MDUniversity of Maryland

Vice Chair of Clinical Affairs

Billina Shaw, MD FAPAMedical Director of Mental Health ServicesPrince George’s County Health Department

Nicole Dempsey Stallings, MPP

Vice President for Policy & Data AnalyticsMaryland Hospital Association

A little background…

Overview: Hospital ED Throughput

Nicole StallingsVice President

Maryland Hospital Association

January 18, 2018MACHE

Maryland’s Performance on CMS ED Throughput Measures

7Source: Joint Chairman’s Report on Emergency Department Overcrowding. December 2017. Submitted by Maryland Institute for Emergency Medical Services Systems and Health Services Cost Review Commission.

• Background:

§ Concern over relatively poor performance on national ED

throughput metrics, particularly in context of Maryland’s

demonstration

− Sensitivity to the appearance of access issues

§ Concern expressed by some Maryland ED physicians

§ MIEMSS supports policy incentives to lessen diversions

§ Pressure from legislators in Annapolis in the form of a

required report that identified solutions

• Result:

§ ED-1b and ED-2b added to state’s Quality Based

Reimbursement Program starting 2018

State Policy to Incentivize

Performance Improvement

8

ED Diversion and Wait Times

Behavioral Health

Medicaid Expansion

Non-Emergent

CasesNursing

Shortage

Care Redesign

Primary Causes of ED Diversion and Long Wait Times

9

Behavioral Health—Mental Health & Substance Use—ED Visits on the Rise

10

26.6%25.2% 25.8%

29.3%

10.8% 11.4% 12.4%13.8%

0%

5%

10%

15%

20%

25%

30%

35%

2012 2013 2014 2015

Mental Health and Substance Use Emergency Department Visit Rate1

ED

Vis

its P

er 1

,000

MD

Res

iden

ts

Mental Health Substance Use

Composition of Behavioral Health ED Visits2

1Source: HSCRC, Maryland All-Payer Model Monitoring Report 2016, June 20162Source: MHA analysis of HSCRC 2016 outpatient claims data. Primary diagnoses used in conjunction with the Agency for Healthcare Research and Quality’s Clinical Classifications Software categories to stratify behavioral health visits

1.2%

1.7%

2.7%

2.9%

2.9%

5.2%

7.3%

13.5%

13.9%

24.2%

24.6%

0% 10% 20% 30%

Miscellaneous mental disorders

Other MHSU disorders

Adjustment disorders

Attention-deficit, conduct, & other cognitive disorders

Delirium, dementia & other cognitive disorders

Suicide & intentional self-inflicted injury

Schizophrenia & other psychotic disorders

Anxiety disorders

Substance-related disorders

Alcohol-related disorders

Mood disorders

0

5

10

15

20

25

Sep14

Dec14

Mar15

Jun15

Sep15

Dec15

Mar16

Jun16

Sep16

Dec16

Mar17

Time Spent in ED is Also Increasing

11Source: MHA adapted from hospital-specific dashboard

Visit Count of Patients with Psychiatric Behavior Complaint with ED Length of Stay Greater Than 24 hours

Num

ber

of P

atie

nts

Complexity of Behavioral Health Patient is on the Rise

12

25

75

125

175

Sep14

Dec14

Mar15

Jun15

Sep15

Dec15

Mar16

Jun16

Sep16

Dec16

Mar17

Visit Count of Patients who Arrive by PoliceN

umbe

r of P

atie

nts

Source: MHA adapted from hospital-specific dashboard

Medicaid ED Visits & Inpatient Admissions Are Increasing, While Use for Other Payers Is Decreasing

13

Medicaid ED visits increased 9 percent, while non-Medicaid

decreased by 7 percent

Medicaid admissions increased 8 percent, while non-Medicaid

decreased by 11 percent

Source: HSCRC inpatient and outpatient claims data, CY 2013 – CY 2016

0%

-8%-10%

-11%

0%

13%10%

8%

-15%

-10%

-5%

0%

5%

10%

15%

2013 2013-2014 2013-2015 2013-2016

Non-Medicaid Medicaid

Change in ED Visits for Patients with Medicaid Relative to Non-Medicaid

Change in Admissions for Patients with Medicaid Relative to Non-Medicaid

0%

-7%

-5%

-7%

0%

14%

10% 9%

-15%

-10%

-5%

0%

5%

10%

15%

2013 2013-2014 2013-2015 2013-2016

Non-Medicaid Medicaid

Medicaid Behavioral Health ED Visits & Admissions Are Skyrocketing

14

Medicaid behavioral health visits increased 39 percent, while non-

Medicaid increased 9 percent

Medicaid behavioral health admissions increased 28 percent, while non-Medicaid decreased 5 percent

Source: HSCRC inpatient and outpatient claims data, CY 2013 – CY 2016. Primary and secondary diagnoses used in conjunction with the Agency for Healthcare Research and Quality’s Clinical Classifications Software categories to distinguish behavioral health admissions and visits from other diagnoses

0%

-8% -8%-5%

0%

25% 25%28%

-10%

-5%

0%

5%

10%

15%

20%

25%

30%

35%

2013 2013-2014 2013-2015 2013-2016

Non-Medicaid Medicaid

Change in Behavioral Health Admissions for Patients with Medicaid Relative to Non-Medicaid

Change in Behavioral Health ED Visits for Patients with Medicaid Relative to Non-Medicaid

0% -1%

10% 9%

0%

31%34%

39%

-5%

5%

15%

25%

35%

45%

2013 2013-2014 2013-2015 2013-2016

Non-Medicaid Medicaid

Nationally, 37 percent of all ED visits are non-emergent

Non-Emergent Patients Need to Be Screened and Take Time Away from Other Patients

15

Emergent Non-Emergent

Source: Uscher-Pines, L., Ph.D, Pines, J., MD, MBA, Kellermann, A., MD, MPH, Gillen, E., & Mehrotra, A., MD, MS. (2013). Deciding to Visit the Emergency Department for Non-Urgent Conditions: A Systematic Review of the Literature. American Journal of Managed Care, 19(1), 47-59. Retrieved May 18, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4156292/

• Nationally, more than 48 percent of hospitals reported a nurse vacancy rate of 7.5 percent or more1

• In Maryland, high nurse retirement and turnover rates results in increased reliance on temporary staffing agencies

Nursing Shortage Makes Staffing Challenging

16

725,188

850,257

1,041,248

0 400,000 800,000 1,200,000

2014

2015

2016

Total Nurse and Allied Health Staff Hours Supplied by Temporary Staffing Agencies2

1Source: Nursing Solutions, Inc. 2016 National Healthcare Retention & RN Staffing Report2Source: The Chesapeake Registry Program

17

Care Transformation and Redesign Contribute to Longer ED Time

• Hospitals are increasingly adopting lifesaving practices intended to meet goals of the demonstration—lower admissions and potentially avoidable utilization

• The result—some patients are in ED longer• Examples of lifesaving practices that have been implemented

including:§ Screening, brief interventions, and referrals to treatment—

or SBIRT§ Cardiac screening and treatment protocols§ Asthma protocols intended to treat acute episodes and

prevent future hospital use

Hospitals are Implementing New Approaches to Address Hospital ED Overcrowding

18

• Creative staffing approaches

• Innovative screening practices

• Improvements with patient flow

• Discharge lounges to relieve inpatient beds

• And more…

Jill RachBeisel, MDUniversity of Maryland

Vice Chair of Clinical Affairs

Psychiatric Emergency Services

Jill A. RachBeisel, M.D.Vice Chair for Clinical AffairsDepartment of PsychiatryUniversity of Maryland School of Medicine

Changing the World of Health Care

Focus Remains On:1. Quality of Care2. Patient Satisfaction3. Reduced Total Cost of Care4. Efficient and Effective Patient Through Put5. Provider and Organizational Satisfaction

Emergency Rooms are the front door of our organizations and a place that we can have a significant impact on cost of care, connection to care and patient education ®Changing Behavior

What is the Problem?

• Increased demand for Psychiatric Evaluations

• Competing priorities between the medically and

psychiatric Crisis

• Often EDs do not have the expertise or appropriate space

to manage this population

• Behavioral issues are disruptive to the general ED

operations

• Backlog of patient boarders- costly ($100/hr~ $2,000/pt)

• Increased Substance Use Disordered Individuals seen

Why Are We Seeing This Problem?

1. Severe reduction of psychiatric bedsÞ 1955- 558,922 beds in U.S.Þ 2010- 43,318 Psychiatric bedsÞ 2012- 38,847 and falling

2. Shorten Lengths of Stays on Inpatient units3. Reduction in Community Programs – businesses closing4. Public or no Health Insurance5. Decreased access to care- long waits6. Increase in Substance Use Disorders (SUD) in our

Society

** 1 in 8 ED patients have a Mental Health or SUD Problem.

Changes to Consider

Changes need to be considered on multiple levels:

1. Provider/Staff Level Changes

2. Organizational Level Changes

3. System Wide Changes

Provider / Staff Level Considerations

• Current thinking: We need a change!• Patients who come to the ED must be admitted for safety

reasons• ED physicians see this as a high risk area and admit

automatically to mitigate risk to themselves and the hospital• Crisis interventions need to occur, treatment started and

appropriate disposition needs to be planned• Reality Check:

• Majority of Psychiatric Emergencies can be stabilized in < 24 hrs.

• 70% of Psychiatric ED patients can be discharged safely

Provider & Staff Approach to Care Changes

1. Skilled Mental Health Staff-Crisis Evaluators2. Knowledge of Brief Interventions to alleviate crisis3. Establishment of Treatment Protocols for the ED

Physicians when a Psychiatrist is not available- (Access to Psychiatric Consultation via live or Tele-mental health)

4. ED Care Managers/Social Workers to assist with aftercare planning, who have full knowledge and working relationship with community programs

Individual Treatment Planning with access to:

Crisis beds

Outreach Programs

Next Day Partial Programs

Out Patient Appointments

Individual Safety Plans

Implement SBIRT in Your ED

Screening, Brief Intervention and Referral to Treatment

Using Peer Recovery Coaches who have experience with addictions themselves and are trained in Patient Engagement, Crisis Assessment, Motivational Interviewing and Referral to AddictionTreatment

Has made a significant impact on High utilizers and getting individuals with addiction where they need to be- in Treatment and out of the ED!

Program/Organizational Considerations

A. Designing a separate, designated space for Behavioral Health Patients in the ED-Behavioral Unit- Part of & adjacent to the General Adult ED- Patients are cleared medically and moved to EDBU- Area is secured for EP patients and those certified- Remain ED patients- can be moved back if medically necessary at any point

WHY? Psychiatric patients stabilize faster and have better resolution of crisis in a quiet, sensitive environment where they can be managed by MH staff.

B. Walk-in Urgent Care- medication refills

System Level Considerations

Advocacy for :1. Statewide Dashboards- know bed availability

2. Use of Centralized Data Base- CRISPa. Ability to identify high utilizers of ED servicesb. Plans of Care can be developed and shared

“Mr. Jones, you were just seen, the plan that was developed was…… did you follow through?... Do you have your

medication? Did you keep your appointment?”

In Conclusion…

This is a National Problem that will take:

* Creative Thinking* Improved Education to Providers* Increased Resources* County and State Wide Advocacy

Billina Shaw, MD FAPAMedical Director of Mental Health ServicesPrince George’s County Health Department

Building a Healthier Prince George’s County

Rushern L. Baker, IIICounty Executive

PRINCE GEORGE’S COUNTYHEALTH DEPARTMENT

Behavioral Health Diversion through Care Coordination

Billina R. Shaw, MD, FAPAMedical Director Mental Health Services

Maryland Association of Healthcare ExecutivesJanuary 18, 2018

Discussion questions

Question:

ED Environment

What are we doing well and what could we do better?

Examples of the “ideal psychiatric ED”

Question:

ED Population

What is unique about the patients seeking treatment in the ED setting?

Are there socioeconomic and diagnostic characteristics that set this population apart?

Question:

ED Intervention

Almost all of psychiatric intervention in the ED is handled by case workers (non-physicians). Is this

reasonable?

Do you think we could alleviate some of the problems if we had psychiatrists in the ED?

If you had a magic wand, how would ED intervention change?

Question:

ED Resources

What are the options for these patients (inpatient, IOP, close follow up, none of the above)?

What programs are working? Which are not?

Question:

Prevention

What programs are you seeing to divert care away from the ED?

What works & what does not work?

Q&A