A Better Approach to Crisis Behavioral Health

Original article published on Becker’s Health IT & CIO Review

Mark Alter, M.D., InSight Associate Medical Director of On-Demand Services

By: Mark Alter, M.D.

Today’s hospital emergency departments (EDs) are facing a perfect storm of behavioral health challenges. A combination of professional shortages and rapid growth in need for behavioral health services is creating significant supply and demand issues across U.S. communities. The overwhelming reality is that 42.5 million Americans struggle with mental health conditions, and professional shortages exist in all 50 U.S. states.

For many communities, the hospital ED has become one of the primary entry points for behavioral health access. Yet, few EDs are equipped with the expertise to handle the scope and complexities of this evolving challenge, leading to lengthy wait times and overcrowding, especially for patients in needs of psychiatric care.

To improve the outlook, hospitals are increasingly turning to the promise of on-demand telepsychiatry—an approach to care providing psychiatric evaluation or consult as needed via videoconferencing. These forward-looking care delivery models not only improve response times and access to services, but they also positively impact patient satisfaction and the bottom line.

The ED Behavioral Health Challenge: A Deeper Look
Current estimates suggest that one in eight ED visits involves a mental health condition, yet patients in need of evaluation often wait much longer than those in need of general medical care. One report found that 23 percent of psychiatric patients had emergency visits that were longer than six hours and 7 percent waited longer than 12 hours—that’s compared to 10 percent and 2.3 percent of other medical patients respectively. In addition, almost 21 percent of patients in need of an inpatient psychiatric bed wait between two and five days.

In terms of adequate staffing for psychiatric issues, today’s hospitals face the same supply and demand issues as consumers in need of services, especially in rural communities, where the existence of even one qualified psychiatrist is often lacking. EDs typically have limited or non-existent in-house hospital expertise available to them, and patients must wait until an appropriate professional is available. These present-day realities lead to crowded ED waiting areas, protracted waits, and the common practice of “boarding” individuals in need of psychiatric evaluation.

The Growing Influence of ED Telepsychiatry Models
Overall, hospital executives are prioritizing telemedicine models to prepare for value-based care. The “2017 U.S. Telemedicine Industry Benchmark Survey” revealed that 51 percent of executives rank deployment and adoption of telemedicine high strategically.

On-demand telepsychiatry models are certainly gaining traction as hospital EDs look to more effectively deliver behavioral health care and address the growing need for services. Provided via video-conference, telepsychiatry providers offer on-call professionals that can be accessed based on need. This framework enables telepsychiatrists to deliver care remotely to numerous organizations at once, increasing efficiency and workflows for all stakeholders.

Credentialed telepsychiatrists first collaborate with ED physicians, nurses and social workers, and review a patient’s medical record. An evaluation is then conducted with a patient in a private area through a computer, tablet or other mobile device. Ultimately, the goal of these one-time encounters is to ensure timely recommendations and triage of patients to the most appropriate level of care. On-demand providers provide valuable consultation services to ED staff and can also prescribe medications directly.

Benefits of on-demand telepsychiatry in the ED include:

Early stabilization and better outcomes
Timely psychiatric treatment initiated in the ED promotes earlier stabilization of conditions and improves patient safety—for both those facing a psychiatric crisis and other patients in the ED. It also ensures patients are triaged to the appropriate level of care or community service.

For instance, it is not uncommon for police officers in some states to bring individuals behaving erratically directly to the ED for psychiatric evaluation. Many of these patients do not require inpatient psychiatric hospitalizations, which can be often be avoided by having timely access to psychiatric professionals who can determine the appropriate level of care.

Many telepsychiatrists also report that patients in crisis situations, particularly those who are agitated or paranoid, can feel less intimidated by video conferencing as opposed to in-person evaluation.

Increased patient throughput
When evaluations are conducted in a timely manner, ED providers can help get patients to appropriate levels of care, opening needed beds to other patients and improving wait room crowding.

Greater patient satisfaction
A combination of timely evaluation and the right expertise ensures a better overall experience for any patients in crisis, including those with behavioral health concerns. When patients are forced to wait for hours or days to see a behavioral health professional, frustration is understandable.

Lower costs
Timely access to care lends to greater efficiencies in the ED and positive bottom-line impacts. In addition, telepsychiatry reduces the need for full-time emergency psychiatrists and ongoing recruitment costs and challenges.

Many hospitals—especially those in rural areas—simply lack the financial resources needed to hire specialized behavioral health professionals to provide services the ED. Additionally, hospitals benefit from the on-demand model by paying for usage as opposed to a full-time equivalent. EDs also reduce liabilities with timely access to on-demand telepsychiatry services, minimizing the potential for litigation that might otherwise occur if conditions escalate and difficult situations arise.

Reduced provider burnout
This approach to care also takes the burden off in-person psychiatric providers who are on call or responsible for covering night-shifts. Telepsychiatrists can work these shifts remotely from another location, even in different time zones, offering added flexibility and an enhanced work/life balance—critical components in addressing provider burnout.

Providing a telepsychiatry resource can also reduce stress on ED directors and other ED providers who do not have the specialty training in psychiatry, but are often faced with treating psychiatric patients.

Future Crisis Behavioral Health Models
While the current outlook on behavioral health professional shortages is grim, the good news is that telepsychiatry holds great promise for filling needed gaps, especially in critical environments such as EDs. Hospitals can realize notable gains by leveraging on-demand telepsychiatry services to improve outcomes, patient and provider satisfaction and the bottom line.

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