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 California: the price of privatizing psychiatric care

California may privatize a state mental health hospital as a cost saving measure. However, critics are worried that Correct Care Recovery Solutions, the selected contractor, will achieve cost savings through dangerous reductions in care quality. The California Mental Health Services Authority—the consortium of California county mental health agencies—is proposing a facility which would serve around 250 civilly-committed patients. Additional beds are needed due to a persistent and historically high need for the most dangerous and severe of the state’s mentally ill.

Backlog

The current network of state hospitals houses people who are charged with crimes but found mentally incompetent to stand trial or not guilty by reason of insanity. In June, the waiting list for hospital beds reached a five-year high of 700 individuals. The average wait time for an individual not found competent to stand trial is two months, but many are forced to wait several months.  Those patients found incompetent to stand trial who do not have access to a bed are forced to wait in county jails, typically in Los Angeles County.  In county jails, patients have access to basic mental health care but long-term psychiatric treatment is often delayed. Other patients, those who are civilly-committed, are housed in local psychiatric hospitals.

Costs

The costs are significant regardless of where patients are housed. It can cost between $600 and $1,300 a day to house civilly-committed patients in local psychiatric hospitals in Los Angeles County. When patients are eventually transferred to state hospitals, counties are still obligated to pay for the care provided to patients, and the state bills about $650 per patient, per day. In 2015, Los Angeles County, alone, spent $55 million on patient care in state mental health hospitals.

Correct Care

The contractor, Correct Care, says it can cut the state’s cost by 10 percent. However, the promise of cost savings through privatization has a complex history. The Department of Justice (DOJ) announced in August 2016 that it would end its use of private prisons noting that private facilities are both less safe and less effective than government run facilities. Soon after, the Obama Administration announced it would take steps to move away from the use of for-profit (private) immigration detention facilities. Privatization of state psychiatric facilities poses similar problems to those which led to the administration’s policy on prisons and immigration facilities.

Privatized State Hospitals: South Florida State Hospital

If California moves forward with its plan, the state will not be the first to privatize a state mental health hospital. The South Florida State Hospital was one of the first in the U.S. to be privatized.  The Florida hospital was managed by a division of GEO Group—a private prison contractor—until 2014, when Correct Care Solutions bought the unit. Following three deaths in the facility, in 2011, Florida’s Department of Children and Families investigated the hospital. In one of the deaths, a heavily medicated patient was found dead in a bathtub with water so hot the patient’s skin sloughed off his body. Investigators determined that Correct Care was addressing the problems. However, between 2011 and 2015, investigators verified 19 more claims that staff abused, neglected, or failed to properly supervise those in their care. Some of those instances of abuse and neglect included a technician throwing a patient to the ground and a patient jumping to his death from the eighth floor of a parking garage. Those opposed to privately run mental health institutions cite understaffing as a key cause of such abuse and neglect.

State-run hospitals

The state-run hospitals are not immune from criticism and instances of patient harm. In 2014, 3,500 patient-against-patient assaults were recorded in California. Metropolitan State Hospital in Norwalk admits the type of civil-commitments which would be transferred to the hypothetical Correct Care facility. Between 2011 and 2015, the California Department of Public Health investigators found at least 55 deficiencies at Metropolitan related to a patient’s harm, abuse, neglect, and restraint.

Access

There is no dispute that California requires additional mental health hospital beds. However, regardless of who will operate additional mental health facilities, lawmakers and stakeholders in California must be careful that the wellbeing of patients is not exchanged in a bargain for a lower rate.