Strategic Approach to Care Coordination Drives Better Outcomes in ER

Individuals who live with a mental health disorder can be vulnerable when it comes to their healthcare, particularly as it relates to the quality and continuity of their health and mental healthcare. Those with chronic or serious mental health disorders often have complex health and behavioral health issues that require services from multiple providers and systems, including hospitals, behavioral healthcare specialists and community-based support services. While coordinating this care is critical, it is often challenging—or even overlooked—in the complex, sometimes fragmented U.S. healthcare system.

As a physician, I have witnessed first-hand hospitalizations that could have been prevented if individuals with mental health disorders had received appropriate support as they transitioned from different levels of care. When a patient leaves an emergency department or a hospital, there must be a plan in place to help them transition in a consistent and coordinated manner to any additional services and treatments they might need, whether these services address a mental health condition, a substance use disorder, or both. Failure to ensure coordinated care transitions can lead to undesirable outcomes, such as unnecessary hospital readmissions, exacerbation of symptoms (The Joint Commission, 2012), and increased risks for homelessness, incarceration, and suicidal behaviors (Tomita & Herman, 2015; Viggiano et al., 2012; Vigod et al., 2013).

Emergency departments and care transitions

The need for clear and thorough care transitions is particularly high in emergency department settings. Research indicates that individuals who have mental health disorders use the emergency department for care at higher rates than the general population. (Baillargeon et al., 2008; Hackman et al., 2006; Merrick, Perloff, & Tompkins, 2010, Niedzwiecki et al., 2018). Emergency departments are often the primary source of medical care for individuals who are the most vulnerable, including those with chronic mental health disorders and limited or no health insurance. Ensuring that discharged patients have continuous and coordinated care is essential, but particularly challenging in emergency departments which may not have the capacity or training to prioritize care transitions. The Bizzell Group has been fortunate to support numerous federal and state initiatives, including for the Substance Abuse and Mental Health Services Administration (SAMHSA) and National Institutes of Health (NIH), that advance the quality of care and outcomes for individuals with mental health disorders, including promoting evidence-based care transition models for emergency departments.

Strategies that can improve emergency department care transitions for individuals with mental health disorders include (National Action Alliance for Suicide Prevention, 2019; Nordstrom et al., 2019; Pincus, 2015):

• Designing and implementing interventions that can be easily integrated into the workflow of the emergency department without creating excessive burdens on staff time.
• Partnering with community-based organizations to improve and facilitate referrals. Some emergency departments partner with mobile crisis teams that can quickly make referrals and connect patients to community services—a “warm handoff”—and these models have particular utility for those who exhibit suicidal risks/behaviors. This connection can be by phone or in-person.
• Using components of successful care transition models. Strategies might include designating trained care “coaches” or advocates in supportive roles, initiating planning before the patient is discharged, actively including the patient and any caregivers in post-discharge planning, and ensuring rapid follow up visits or calls by a care coach/advocate for a designated period of time.

One successful care transition model that could help inform transitional models for patients with mental health disorders is the Screening, Brief Intervention, Referral to Treatment (SBIRT) model (Bernstein and D’Onofrio, 2013). SBIRT is an evidence-based emergency department care transition model for patients with substance use disorders that has been effectively implemented into emergency department workflow (Barata et al., 2017, Biroscak et al., 2019). It involves screening for risky substance use, a brief intervention between the patient and emergency department provider that educates and encourages behavior change, and referral to treatment that has an enhanced referral process for selecting/accessing services and includes follow-up after referral.

The use of care advocates in the emergency department

Trained care advocates or “coaches” can be effective allies and resources to help patients with mental health disorders safely transition from the emergency department or hospital (National Action Alliance for Suicide Prevention, 2019; Pincus, 2015). Some trained coaches may be “peers” who have personal experience with a mental health disorder and are in a unique position to connect with patients in this situation. They can support the care team in various coordinated ways, such as by helping these patients make informed decisions about ongoing and continuing healthcare, providing support to them post discharge, and facilitating links to services and resources.

I have worked alongside many care advocates that partner with nurses and social workers to develop plans that engage patients with mental health disorders in their own care and follow-up. I have witnessed these patients become better advocates for themselves as a result and better able to navigate barriers to their own care.

Continuity of care must remain a top priority for our healthcare system, especially during this pandemic as more people struggle to manage their mental health and substance use disorders while emergency departments, and healthcare systems may be taxed by COVID-19. More research is needed to better understand those patients who are most at risk during transitions and which interventions result in the best outcomes (National Quality Forum, 2017). Creating workable solutions to these complex access and service delivery challenges can and lessen the burden on our care teams, healthcare institutions, available resources, and more importantly, can save lives.

Anton Bizzell, MD, is the founder, president and CEO of The Bizzell Group, a strategy, technology and consulting firm.

***

References

Baillargeon, J., Thomas, C. R., Williams, B., Begley, C. E., Sharma, S., Pollock, B. H., … Raimer, B. (2008). Medical emergency department utilization patterns among uninsured patients with psychiatric disorders. Psychiatric Services, 59(7), 808–811. https://doi.org/10.1176/ps.2008.59.7.808

Barata, I. A., Shandro, J. R., Montgomery, M., Polansky, R., Sachs, C. J., Duber, H. C., Weaver, L. M., Heins, A., Owen, H. S., Josephson, E. B., & Macias-Konstantopoulos, W. (2017). Effectiveness of SBIRT for Alcohol Use Disorders in the Emergency Department: A Systematic Review. The Western Journal of Emergency Medicine, 18(6), 1143–1152. https://doi.org/10.5811/westjem.2017.7.34373

Bernstein, S. L., & D’Onofrio, G. (2013). A promising approach for emergency departments to care for patients with substance use and behavioral disorders. Health Affairs, 32(12), 2122–2128. Retrieved from https://content.healthaffairs.org/content/32/12/2122.short

Biroscak, B. J., Pantalon, M. V., Dziura, J. D., Hersey, D. P., & Vaca, F. E. (2019). Use of non-face-to-face modalities for emergency department screening, brief intervention, and referral to treatment (ED-SBIRT) for high-risk alcohol use: A scoping review. Substance Abuse, 40(1), 20–32. https://doi.org/10.1080/08897077.2018.1550465

Hackman, A. L., Goldberg, R. W., Brown, C. H., Fang, L. J., Dickerson, F. B., Wohlheiter, K., … Dixon, L. (2006). Brief reports: Use of emergency department services for somatic reasons by people with serious mental illness. Psychiatric Services, 57(4), 563–566. https://doi.org/10.1176/ps.2006.57.4.563

Hanrahan, N. P., Solomon, P., & Hurford, M. O. (2014). A pilot randomized control trial testing a transitional care model for acute psychiatric conditions. Journal of the American Psychiatric Nurses Association, 20(5), 315–327. https://doi.org/10.1177/1078390314552190

Merrick, E. L., Perloff, J., & Tompkins, C. P. (2010). Emergency department utilization patterns for Medicare beneficiaries with serious mental disorders. Psychiatric Services, 61(6), 628–631. https://doi.org/10.1176/ps.2010.61.6.628

National Action Alliance For Suicide Prevention. (2019). Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care. Education Development Center, Inc. Retrieved from https://www.samhsa.gov/sites/default/files/suicide-risk-practices-in-care-transitions-11192019.pdf

National Quality Forum. (2017). Emergency Department Transitions of Care: A Quality Measurement Framework (p. 73). National Qualty Forum.

Niedzwiecki, M. J., Sharma, P. J., Kanzaria, H. K., McConville, S., & Hsia, R. Y. (2018). Factors Associated With Emergency Department Use by Patients With and Without Mental Health Diagnoses. JAMA Network Open, 1(6), e183528. https://doi.org/10.1001/jamanetworkopen.2018.3528

Nordstrom, K., Berlin, J. S., Nash, S. S., Shah, S. B., Schmelzer, N. A., & Worley, L. L. M. (2019). Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document. Western Journal of Emergency Medicine, 20(5), 690–695. https://doi.org/10.5811/westjem.2019.6.42422

Pincus, H. (2015). Care transition interventions to reduce psychiatric rehospitalization. Alexandria, Virginia: National Association of State Mental Health Program Directors. Retrieved from https://www.nasmhpd.org/sites/default/files/Assessment%20%233_Care%20Transitions%20Interventions%20toReduce%20Psychiatric%20Rehospitalization.pdf

The Joint Commission. (2012). Transitions of Care: The need for a more effective approach to continuing patient care (Hot Topics in Health Care). Retrieved from https://www.jointcommission.org/assets/1/18/Hot_Topics_Transitions_of_Care.pdf

Tomita, A., & Herman, D. B. (2015). The role of a critical time intervention on the experience of continuity of care among persons with severe mental illness following hospital discharge. The Journal of Nervous and Mental Disease, 203(1), 65–70. https://doi.org/10.1097/NMD.0000000000000224

Viggiano, T., Pincus, H. A., & Crystal, S. (2012). Care transition interventions in mental health. Current Opinion in Psychiatry, 25(6), 551–558. https://doi.org/10.1097/YCO.0b013e328358df75

Vigod, S. N., Kurdyak, P. A., Dennis, C.-L., Leszcz, T., Taylor, V. H., Blumberger, D. M., & Seitz, D. P. (2013). Transitional interventions to reduce early psychiatric readmissions in adults: systematic review. The British Journal of Psychiatry, 202(3), 187–194. https://doi.org/10.1192/bjp.bp.112.115030