The EmPATH Model Streamlining Care with Specialized Psychiatric Emergency Services Kaiser-Steinberg Institute Forum January 31, 2018 Scott Zeller, MD Seth Thomas, MD

Scott Zeller, MD Seth Thomas, MD VP Acute Psychiatry CEP America Director of Quality & Performance Emergency Medicine CEP America

Intake Processing Output Throughput

Flow Matters!

Definition: Psychiatric Boarding Psychiatric patients in medical emergency departments who are medically stable yet waiting for evaluation or disposition Often these patients are kept with a sitter, or in “holding rooms” or hallways on a gurney – some languishing for ours in physical restraints, often with no concurrent active treatment

Problem: Psychiatric Patients are Victims of ED Overcrowding The typical ED experience: Loud / Noisy Auditory & visual overload Untrained staff Lack of specialists Lack of correct medications Error-prone environment Lack of showers & exercise

ED Boarding… Increases frustration Decreases patient satisfaction Decreases core measure compliance Increases costs Increases adverse outcomes INCREASES MORTALITY

Nicks B, Manthey D. Emerg Med Int. 2012 Impact of Psychiatric Boarding Boarding is costly, medically, ethically and financially Symptoms often escalate & worsen in EDs Average cost to board a psychiatric patient estimated at $2,264 Studies showing average psychiatric patient in medical emergency departments boards for an average of between 8 and 34 (!) hours Psych patients boarding in an ED can cost that hospital more than $100 per hour in lost income alone (Treatment Advocacy Center, 2012) Nicks B, Manthey D. Emerg Med Int. 2012

Psychiatric Patients are Disproportionately Affected ED staff spend twice as long finding inpatient beds 2012 Harvard Study 11.5 hours per ED visit 15 hours waiting for inpatient beds 2012 CHA Study: Average adults wait over 10 hours until transfer after the decision is made Studies showing average psychiatric patient in medical emergency departments boards for an average of between 8 and 34 (!) hours

Psychiatric patients are especially at risk

LOS Psychiatric Patients Psychiatric Patients Pay the Price 3.2 x longer 18.2 hrs 5.7 hrs LOS Medical Patients LOS Psychiatric Patients

414.6% 44.1% 14.8% 6.9% General Population Emergency Department ED Mental Health ED Suicidal Ideation

Who’s the real Gomer? An unsophisticated person; a yokel. Origin An acronym that stands for "Get Out of My ER". The term was popularized by the 1978 novel The House of God by Samuel Shem (pen-name of Stephen Bergman). In this book, the word is applied to patients who are frequently admitted with complicated but uninspiring and incurable conditions.

Intake Processing Output Throughput

So what can we do? We need to think and act in a proactive, innovative fashion

Modern Solutions

Boarding Solutions Suggested Most suggestions still follow concept that virtually all emergency psychiatric patients need hospitalization as the only disposition Results in far too many patients being unnecessarily hospitalized at a very restrictive and expensive level of care Roughly equivalent to hospitalizing every patient in an ED with Chest Pain (typically only 10% of such patients get hospitalized)

Wrong Solution: Treating at the Destination Instead of the Source All these solutions call for more availability for hospitalizations, nothing innovative at the actual ED level Change in approach needed – beginning with recognition that the great majority of psychiatric emergencies can be stabilized in less than 24 hours To reduce boarding in the ED, shouldn’t the approach be at the ED level of care?

Zeller’s Six Goals of Emergency Psychiatric Care Exclude medical etiologies and ensure medical stability Rapidly stabilize the acute crisis Avoid coercion Treat in the least restrictive setting Form a therapeutic alliance Formulate an appropriate disposition and aftercare plan Zeller, Primary Psychiatry, 2010

Allen MH et al. Journal of Psychiatric Practice, 2003 Moving Outside the ED A 2003 survey of psychiatric consumers reported that a majority had unpleasant experiences in medical emergency facilities and would prefer treatment in a specialized Psychiatric Emergency Service location. Allen MH et al. Journal of Psychiatric Practice, 2003

EmPATH Units Emergency Psychiatric Assessment Treatment & Healing Crisis Stabilization Units (or “Psych ER”) provide a calming, healing, comfortable setting completely distinct from the medical ED where prompt access to a psychiatrist can help lead to timely and dramatic improvement for patients experiencing a psychiatric emergency. A Revolutionary Approach to Emergency Psychiatric Care

Physical Space Design Key Take-Away: Calming environment separate from ER that prioritizes healing and access to care Large, open milieu space where patients can be together in the same room – high ceilings and ambient light. All can easily self-access food, drinks, linens, phones, books, games, TV. Ample room for walking about or pacing. Space to move about and engage in socialization, discussion, and therapy. Some feature outdoor relaxation gardens “Per chair” model, outfitted with recliners. Space recommendation: 80 sq ft per patient; 36 sq ft patient area around the recliners Open nursing station w/instant access to staff - No “bulletproof Plexiglas” separating the patients 1-2 Calming Rooms (unlocked spaces) - Avoid locked rooms or restraints

Physical Space Design

Patient Benefits Immediate care setting change from chaotic ED to a calming, “trauma-informed” environment with restraint elimination Coercion avoided, all about engagement and individual decisions; staff available around the clock. Peer support specialists onsite. Multi-disciplinary team treatment and resources available, discharge planning, family contact, outpatient provider connections Rapid evaluation by a psychiatrists after arrival, comprehensive care plan development; patients may stay up to 23 hours till dispo

Hospital Benefits EMTALA-compliant for voluntary/involuntary mental health crises; take all medically-stable patients immediately from ER Not alternative destination to inpatient, but a separate “psych ER” where all evaluation, treatment and dispositions are made Move behavioral health care out of the ER into more appropriate space for healing, opening up beds in the ER for medical patients Significant reduction in admission rates, up to 80%, as patients respond very well to site and interventions Even inpatient units benefit -- eliminate unnecessary, denied pay 1- 2 day inpatient admissions

Thank You! Questions?