Addressing the challenges behavioral health patients present when in crisis

Access to proper treatment for patients with behavioral and mental health issues has become a major issue in the United States and has received attention from the public and Congress. But, there are unique issues when a behavioral health patient appears at a hospital emergency room and the hospital must abide by the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 U.S.C. §1396dd). Catherine M. Greaves, counsel, and Kristin M. Roshelli of King & Spaulding, LLC addressed the challenges hospitals face in emergency situations with behavior health patients in a Health Care Compliance Association webinar held on July 25, 2017.

The behavioral health patient and EMTALA

When a patient comes to the hospital’s emergency department (ED) with a behavioral health condition and requests emergency treatment, the patient (1) may be a danger themselves or to others, (2) may lack orientation, which is interfering with his or her ability to meet basic needs such as nutrition or safety, or (3) may have an underlying mental illness. Patients may be suicidal or homicidal, assaultive or combative, delusional or psychotic, or experiencing withdrawal from drugs or alcohol.

Hospitals must ensure that EMTALA requirements are met, including conducting a medical screening as well as a psychiatric evaluation, properly stabilizing the behavioral health patient if a n emergency medical condition (EMC) exists, and addressing transfer issues, including the vehicle used to transfer have been addressed. In addition, the hospital must have policies and procedures that adequately reflect EMTALA requirements and must provide education and training on serving behavioral health patients for the ED and other hospital staff, including security. If the hospital is in a state that has laws requiring mental health patients to be evaluated and treated at designated facilities may clash with or be more stringent than EMTALA. Hospitals must not disregard EMTALA requirements.

Concerns specific to behavioral health patients

Greaves said that EDs have become the “de facto dumping grounds for psychiatric patients.” One out of 8 ED visits are for mental health disorders or substance abuse, which represents a large percentage when compared to the population as a whole. In addition, she pointed out a 2008 survey conducted by the American College of Emergency Physicians that found that 99 percent of emergency physicians reported admitting behavioral health patients daily. According to Greaves, much of this is due to the lack of available designated psychiatric hospital beds and the decrease in state facilities for behavioral health patients. Currently, there are only 14 beds available per 100,000 people, which represents a decrease of 90 percent since the 1990’s, and is the number of beds available in 1850. The optimal number of beds is 50 per 100,000.

MSE for behavioral health patients

MSE for behavioral health patients consists of two steps, an initial medical screening to rule out underlying medical/organic causes for symptoms followed by a psychiatric review once medical clearance has been determined. Greaves stressed the importance of conducting the medical screening examination before doing a psychiatric evaluation to rule out medical conditions that can trigger behavioral symptoms. As examples, she noted that drugs and alcohol can mask underlying medical conditions and infections, especially in the elderly, can trigger psychiatric behavior. She also emphasized that appropriate hospital personnel conduct screening.

Stabilization

Greaves noted that patients with behavioral health conditions are not quickly stabilized. Patients must be stabilized enough to tolerate a transfer or be discharged. Hospitals should consider whether the patient is protected and prevented from injuring or harming self or others; when using chemical or physical restraints, and is the underlying EMC stabilized. Although some patients refuse treatment, suicidal patients may not refuse medical and psychiatric evaluations and stabilizing treatment. If the patient is being transferred with restraint for stabilization, how long will the stability last and how long is the trip.

If the ED decides to transfer a patient that is not stable, the physician must explain the reason for the transfer and certify that the benefits outweigh the risk. The transfer, however, must comply with all of the other EMTALA regulations. Within the hospital’s capabilities, treatment must be provided to minimize the risk of harm, the receiving facility that agrees to accept the transfer must be contacted, and appropriate information must be sent to the receiving facility.

Transfer challenges

Behavioral health patients are transferred at higher rates than nonpsychiatric patients with much longer wait times for the transfer because of issues locating an available bed in a national shortage, insurance acceptance and prior authorization delays, and arranging transportation. When it comes to choosing the vehicle to transport behavioral health patients, there is no single method that is full proof. Hospitals should balance minimal interference with the patient’s dignity and self-respect, reduce the likelihood of harm to self or others, and prevent the transport experience from being perceived as a traumatic event.

Options for transportation include ambulance, police care, private vehicle, and a hybrid, but all present problems. An ambulance may not be a good choice because it is filled with objects that can be utilized to harm self or others and there is no barrier to protect the driver. A police car may traumatize the patient, a support person is not allowed, there is no established protocol for safe transport of behavioral health patients, and there is limited ability to intervene if a medical emergency occurs during transport. In addition, both ambulances and police vehicles brings a public cost. Private vehicles should not be used because family are generally not capable of providing appropriate care. Some states laws allow variations that make up a hybrid that may include the involvement of Mental Health Crisis Teams or unmarked police vehicles.

Highlight on New Hampshire: Behavioral health services streamlined

New Hampshire plans to streamline its mental health and substance abuse programs for children, including unifying the delivery of mental health and substance disorder services to help during the transition from childhood to adulthood through the newly established Bureau of Children’s Behavioral Health. The Bureau’s establishment followed state lawmakers’ passage last week of a bill (SB 534-FN) directing the state’s Department of Health and Human Services (DHHS), along with other state agencies, to coordinate and integrate children’s mental health services in a system of care. The goal is to transform a straining mental health and substance use delivery system and provide a greater focus on the services and supports of children. The Bureau is part of the DHHS Division of Behavioral Health which itself was created in March. The proposal uses those two departments to create the framework but does not add new services, so no state money is attached to the bill for the first year. An additional $180,000 is included annually for the next three years to pay for more staffing.

Prior to the passage of the bill, proponents had argued that changes over the past 15 years within the DHHS organization structure had an adverse impact in the area of mental health in general, and children’s services in particular. The National Alliance on Mental Illness, in testimony before state lawmakers, had noted that the New Hampshire’s Children’s Mental health Director position had been vacant for seven of the past eight years. State action plans on rebuilding the mental health system were silent about children’s mental health issues. Combined with other factors, New Hampshire had a vacuum regarding strategic planning for children’s mental health.

The state had been studying the approach for the past several years through the New Hampshire Children’s Behavioral Health Collaborative.

Executives focused on population health, clinicians want better mental health integration

Population health management, a hard-to-define concept that loosely means (or seems to mean) strategies employed in a cost-effective manner to improve the health outcomes of a community as a whole, may not be a primary concern for clinicians. The New England Journal of Medicine (NEJM) Catalyst Insights Council surveyed clinicians, clinician leaders, and executives on their health care delivery priorities and found that many believed that better integration of mental health care with physical care was the most important way they could improve community health. Clinician comments, however, indicated that they were less enamored with the idea of population health management than proponents may have hoped.

Survey and comments

Out of the 297 responses, 24 percent stated that if they were given $100,000 to spend on changing their clinical practice to improve community health this year, they would invest in mental and behavioral health services. The next highest responses were building interdisciplinary teams and creating community partnerships with other organizations, both at 13 percent. When the same question was imposed with a long-term view ($1 million over the next ten years), behavioral and mental health stayed at the top, at 19 percent.

 The survey also asked respondents about how important they believed population health to be: a fad, essential, or a middle ground. The average score was a 77 out of 100. While in the top quartile, the survey analysis found it to be a “tepid endorsement” in light of how focused organizations are on implementing population health.

The comments received from administrators and executives showed that they hold a more positive view of population health than clinicians. Leaders are focused on the inevitability of transitioning away from fee-for-service, and while they hold some anxiety about the future, population health seems to be a popular option. Clinicians, however, want to maintain a focus on patients themselves rather than an entire population. Those providing the care want their focus to remain individualized.

While one executive of a nonprofit community hospital said that, “Population health management is key to enabling people to take control of their health care needs,” another at a for-profit payer said that precision medicine was as “equally important” as population health, even though the organization focused on the latter. A clinician at a post-acute care provider stated that he has “not been impressed with the vision nor the outcomes of current population health research and programs,” and a leader at a medical school stated that population health is “important but not sufficient.”

Behavioral health integration

Integration studies and discussions rarely mention population health, even though providers and leaders feel that population heath success depends on better provision of mental health services. The idea of behavioral health integration with physical care is not a new one, but has been gaining traction in recent years. Care collaboration has been pushed by the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), but a winning model for mental health care integration has not yet emerged. A Journal of General Internal Medicine article reviewed integration in primary care practices and noted that models requiring significant reorganization were too complex for ready adoption, when compared with “co-location” options. However, when patients show signs of depression when screened in a primary care setting, integrated practices offered treatment faster than other settings.

When behavioral health care is not integrated or co-located, as many as 60 to 70 percent of patients presenting in emergency departments and primary care locations leave without receiving proper treatment. Although some enter the area of health care where mental health problems are exclusively treated, many fail to follow up. Two models have shown particular promise: one where psychiatrists consult on cases where patients have more complicated mental illnesses or fail to respond properly, and another where teams of behavioral health and primary care providers treat mental conditions and other medical conditions simultaneously in order to prevent one improperly managed chronic condition from worsening another.

Highlight on Rhode Island: Wave of health care innovations in Ocean State

The smallest state in America is working to improve its residents’ health through a number of new initiatives. From a pilot program that will provide children with access to behavioral health care in their schools to new programs to compile large-scale data on public health and insurance claims, these innovative projects will enable Rhode Island to track and improve health care.

School behavioral health initiative

Providence Public Schools, The Providence Center, and Behavioral Health Solutions are partnering in a program that will put behavioral health clinicians in two elementary and four middle schools. Rhode Island has a shortage of child behavioral health providers, and  most child psychologists in the state don’t accept insurance, leaving children in the state at risk. The public-private initiative will make it easier for public school children to receive necessary services.  The program will make care more accessible, with specialists on-site and available during school hours, and will allow teachers and principals to directly refer students for help quickly. Clinicians will not bill the school system, but rather will charge the students’ health insurance, including Medicaid and the Children’s Health Insurance Program, for services provided. Providence Mayor Jorge Elorza hopes this initiative will be the first step in providing behavioral health services to all area students in need. The program began with a pilot at West Elementary School, which has made counseling and referral services available to 44 students.

Pilot public health dashboard

Providence was chosen as one of four cities to participate in the Municipal Health Data for American Cities Initiative, launched by the National Resource Center and part of the White House Initiative on Strong Cities, Strong Communities. Providence residents face health challenges that include high chronic disease and related risk factor burdens. Low-income residents and communities of color are disproportionately affected. Providence will employ population-based strategies focusing on high-risk, vulnerable groups to expand the reach and health impact of improvements across sectors. Although it is not yet clear what data will be available through the dashboard, the initiative will frame federal and county data at the municipal level, extract key benchmarks that are embedded in existing city-level data, and create entirely new indicators through big data and social media activity. Elorza hopes to use the dashboard to see where Providence ranks among other cities in New England with regard to the city’s health levels, and then improve to be one of the fittest cities in the region. The other cities chosen to participate are Flint, Michigan; Waco, Texas; and Kansas City, Kansas.

All-payer claims database

Rhode Island recently launched the HealthFacts RI Database, an all-payer claims database that provides medical and pharmacy claims data from all private and public health insurers and administrators in the state, and the most comprehensive collection of health care claims data that the state has ever compiled. The database is intended to help state agencies and researchers learn where health care dollars are going, how effective various uses of dollars are, and track overall trends. It includes data from nearly 825,000 Rhode Islanders–using what the state calls “extensive precautions” to protect patient privacy –with claims totaling $18 billion between 2011 and 2014. Rhode Island is one of 18 states with such all-payer claims databases, though the Supreme Court’s recent decision in Gobeille v. Liberty Mutual Insurance Company makes it more difficult for states to require some plans to report data. The Gobeille Court found that the Employee Retirement Income Security Act (ERISA) preempts Vermont’s law requiring insurers to participate in that state’s all-payer claims database.