Care Integration Pathways for Behavioral Health Patients in Beth Israel Deaconess Hospital-Milton’s Emergency Department Marian Girouard-Spino, RN, MSN, CCM Director of Care Integration Lisa Braude, PhD Senior Advisor, Health Policy & Grant Management Ashley Yeats, MD, FACEP Vice President of Healthcare Quality & Clinical Integration/Chief Medical Officer

Statement of the Problem & Intervention Prolonged ED boarding of BH patients contributes to ED crowding and impedes timely access to ED services Care Integration activities assure accuracy of medication reconciliation in the ED and the development of individualized care plans which ensure comprehensive assessment of collateral patient information and effective handoffs across care transitions.

Key Issues Approx. 95% of all ED boarding was accounted for by ED behavioral health (BH) boarders (~40/month) w/ boarding for up to 21 days in the ED awaiting inpatient psychiatric placement. 1% of ED patient registrations and consumed 11% of ED resources, impeding access of other acute patients to ED services. More than 3 BH boarders (defined as boarding in the ED for more than 2 hours after the decision to admit/transfer to a higher level of care) was strongly associated with DPH mandated activation of Code Help disaster plan activation.

Program Goal Support the Care Integration Program (CI) to reduce ED length of stay & improve patient care for boarding long-stay (>8hours) BH patients perpetuated by spike in ED volume: Closure of Quincy Medical Center Shortage of inpatient psychiatric beds Statewide opioid crisis Changing patient demographics

Overview of the Care Team Masters-prepared RN Director of Care Integration Two co-located Licensed Independent Clinical Social Workers from the regional Behavioral Health Emergency Services Provider (South Shore Mental Health) Part-time Music Therapist & Chaplain ED physician and RN champions Pharmacist Security officer Administrative & analytical support

Progress to Date

Based on Equation of Line, Trend Over Time Key Outcome Based on Equation of Line, Trend Over Time   Oct-14 Dec-16 % Change ER LOS 3.49 3.76 8% BH Boarder LOS 35.73 30.72 -14% In spite of the December 2014 closure of Quincy Medical Center leading to a spike in ED volume and BH boarding, a shortage of inpatient psychiatric beds and a statewide opioid crisis, the Care Integration Team was able to reverse an upward trend in length of stay for BH patients. FY16 interventions resulted in a 14% average LOS reduction for BH boarders, reversing and upward trend and 30% increase in FY15.

Lessons Learned There are significant gaps in the construct of a traditional ED model of care which impede care to ED BH boarders and the ability to provide optimal milieu management. There are barriers within state agencies and payer organizations that perpetuate emergency department patient boarding for BH patients. Barriers to electronic record sharing between disparate providers impede a seamless, integrated and coordinated system of care. Early identification, ED treatment intervention and coordination with community resources decreases ED BH boarding, recidivism and utilization.

For more information, contact: Marian Girouard-Spino RN, MSN, CCM Director - Care Integration   Phone:  617-313-1650 Fax:        617-313-1518 Email:   Marian_GirouardSpino@bidmilton.org