Changing Our Approach to Emergency Department Care

We are developing more expertise to respond to the incarceration crisis engulfing so many peers with behavioral health and intellectual/development disability (I/DD) conditions. In this effort, we have learned that community diversion centers are an essential part of our crisis response capacity. Our focus has been to prevent incarceration in county and city jails. A question now arises about also using this newly developed capacity to prevent overuse of hospital emergency departments.

First, I need to provide a little more background on diversion centers, usually open locations without appointments where a person can walk in for behavioral health care, where a peer or family member can bring someone, or where the police can bring someone in lieu of taking them to jail. Typically, these centers provide care for less than 24 hours before a warm handoff to a care coordinator in the county behavioral healthcare system. A growing number of these centers now are either in operation or under development.

In Bexar County, Texas, home to San Antonio, the Haven for Hope performs this important function. In addition to crisis behavioral health services, this high-end facility also offers primary care services, houses persons who are homeless, and provides job training.

Washington County, Oregon, a suburb of Portland, has developed a diversion center in a donated building adjacent to a mass transit line. Coddington County, South Dakota, has set aside a room in the county office building that serves as a part-time diversion center. And in Anne Arundel County, Maryland, the county has made an arrangement with four behavioral healthcare centers to serve this function.

Anecdotal reports from the field all suggest that these diversion centers are effective in reducing the numbers of persons with behavioral health conditions in our county and city jails. They also are effective in linking these persons with care coordinators in county behavioral health systems. Thus, they have considerable promise for the future for this population. It still remains to be seen whether they can fulfill the same role for persons with I/DD conditions, especially those with co-occurring mental illness.

Now, I would like to explore the potential use of diversion centers to address the issue of hospital emergency room use.

Currently, the number of persons with behavioral health conditions seeking help from emergency rooms is exceptionally high. National data show that one in eight visits to emergency departments in the United States involves mental and substance use disorders. Between 2007 and 2011, the rate of ED visits related to these disorders increased by over 15%. Such visits involving behavioral health conditions are considered potentially avoidable. If these conditions are adequately managed through appropriate outpatient care, then emergency department visits should be rare. These potentially preventable visits also affect hospitals, because behavioral health visits are more than twice as likely to result in hospital admission compared to other visits.

Such emergency department visits also frequently are the occasion for multiple problems: failure to treat in the emergency room; psychiatric boarding on a floor mat; lack of inpatient bed availability, among others.

So, I come to the question: Can our new diversion centers also divert persons with mental health and substance use conditions away from hospital emergency departments? Clearly, we need to develop pilot projects in the community to test this approach. Potentially, not only could money be saved, but also care could be provided more quickly, in a much more humane way.

I hope that this commentary will generate both discussion and action around this question.