Let's take our national mental-health crisis out of the emergency room
Tonight, countless acute mental-health patients desperate for help will arrive at their local emergency room only to be detained under guard for days as they wait for suitable psychiatric care. It's a crisis of health-care delivery that, at a minimum, would benefit from the leadership of a national task force to develop solutions for a problem caused by poor funding for community care.
The issue of mental-health patients being "boarded" in emergencies rooms, whether they arrive there themselves or are brought by police unable to handle a mental-health crisis, is endemic. It's an economic imperative to solve this problem because it wastes resources and, since behavioral treatment has better outcomes the sooner it begins, it's also a moral one.
This comes at a time when we lament the prevalence of mass shootings and a rising number of suicides throughout the United States; removing barriers to decent treatment of anyone in a mental-health crisis should be a top priority.
Today, vulnerable patients and their families suffer needless stress awaiting proper medical treatment in emergency room settings, where staffs aren't trained in providing help for mental-health patients. Typically, staffs put these patients under guard, often in a small exam space where they are confined until a bed becomes available at a mental-health facility. They aren't provided any therapeutic care — and treatment doesn't begin until they're placed elsewhere.
An American College of Emergency Physicians survey of 328 emergency rooms found that roughly 80% boarded psychiatric patients, holding them in a noisy, chaotic emergency room waiting for a transfer to another inpatient facility. In Georgia, for example, waits average 34 hours and often last several days before a psychiatric inpatient bed is available. In Maryland, many emergency rooms board up to a dozen psychiatric patients for days at a time.
Broad agreement exists that what's needed is better coordination of community mental-healthcare on a consistent and ongoing basis, not just when a crisis flares up. Mark Furlong, chief operating officer at Thresholds, Illinois' largest provider of community mental-health services, says when his nonprofit worked closely with managed-care organizations to help 50 highest-risk individuals by providing evidence-based mental-health treatment that included a focus on housing, jobs, and family support, the program halved emergency room visits.
Vinson Yates, chief financial officer at OhioHealth, a 10-hospital, nonprofit health system based in Columbus, Ohio, says improving access to the proper complement of facilities offering appropriate mental-health services would ensure that patients can go to "the right location at the right time" rather than using the ER in a crisis.
"The ideal community structure would ensure that all of our patients have access to mental-health services," says Yates, who notes it's not unusual for patients to spend days in the ER waiting to be transported elsewhere. "In a perfect world, patients in need would present at the emergency room, and we could expediently house and triage them appropriately. But right now ERs are deluged."
Yates says that OhioHealth has actively worked to open up access for mental-health patients, especially those who may be part of typically underserved communities. Working with the U.S. Centers for Medicare and Medicaid Services (CMS), OhioHealth and a multitude of other stakeholders have seen a recent rule finalized that addresses what is known as the Institutions of Mental Disease (IMD) exclusion.
"The IMD exclusion had been in place for decades and was severely limiting the ability of Medicaid patients to receive mental-health services in most any setting other than a crowded hospital ER," Yates says. "The new CMS rule addressing the IMD exclusion will, I believe, open up access to some of our most vulnerable patients."
Yates says OhioHealth and other health-care partners in Ohio are now working with the state's Department of Medicaid to ensure that the CMS rule — which is permissible, not mandatory — is applied in Ohio.
A return to the institutional care of the 1970s isn't in the best interest of patients, of course. Studies show regular clinical intervention coupled with therapy and medications combine to produce an improved quality of life. A patient-centered medical home model for primary care works effectively, but there's a significant deficit in the number of mental-health professionals needed.
New York City has drawn a link between better mental-health outcomes and reduced incarceration rates, investing $130 million over four years in an initiative to reduce the number of mental-health patients in the criminal-justice system. However, few state and federal lawmakers recognize that the costs of mental-health initiatives are defrayed by savings from fewer prison terms, reduced homelessness, and lower emergency room and inpatient costs.
Indeed, mental-health services can be held hostage to budget battles, as is happening in Illinois where Republican Gov. Bruce Rauner and Democratic lawmakers have fought over funding mental-health services, leaving the state without a full budget since last July. Since then, numerous mental-health services have gone unfunded, including grants that help communities hire psychiatrists. The result has been waiting periods as long as two or three months to see a psychiatrist and more patients showing up in emergency rooms.
Furlong says one solution is to align payment incentives so that hospitals, managed-care organizations, primary care providers and community behavioral-health groups can work together effectively for the good of mental-health patients. Under a fee-for-service model, there's little incentive to get the right treatment to mental-health patients, where outcomes are paramount. Medicaid policies are often not aligned with positive mental-health outcomes. For example, home-care nurses have no incentive to flag patients exhibiting signs of depression.
Yates also believes that an additional solution lies in enhanced communication between all providers who treat mental-health patients — from social workers to psychiatrists, ER managers, and primary-care physicians. Central to enhancing that communication is the willingness and the availability of requisite tools for clinicians to share information and develop effective treatment plans.
"There are not enough mental-health professionals, they are not yet coordinating care well enough, and there is simply not enough communication about how to utilize our various resources well," Yates says. "There has to be a high level of coordination, which is incredibly difficult."