1. 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

2. 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.

3. 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.

4. 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

5. 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

6. Progress to Date

7. 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.

8. 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.

9. For more information, contact: Marian Girouard-Spino RN, MSN, CCM
Director - Care Integration
Phone: 
Fax: