Elements of the continuum

ROLE OF HOSPITALS IN CRISIS SERVICES

Although much of the purpose of an ideal crisis system is to divert individuals in behavioral health crisis away from hospital EDs and psychiatric inpatient hospitalization, community hospital emergency departments and medical units, ED-based psychiatric emergency services, community hospital psychiatric units and freestanding psychiatric inpatient facilities are all critically important elements of an ideal crisis continuum.

Psychiatric Emergency Service Programs in Emergency Departments

In some areas, particularly in urban settings with university-based hospitals or tertiary or quaternary care hospitals, certain emergency departments have dedicated psychiatric emergency services (PES), which can provide comprehensive evaluation, monitoring (including 23-hour beds), initiation of treatment and connection with community resources. These specialized PES programs may provide some benefit relative to community-based crisis centers for those who are especially medically complex, unstable or fragile.

More recently, the EmPATH model for ER based PES has been adapted widely for hospitals and communities of varying sizes and capacities. This type of service should be considered as an important component of an ideal crisis system, for those individuals with severe behavioral health crises who also need the services of a medical ER.

A full-fledged collaboration with mobile crisis services (whether provided on site or through telehealth) will permit the mobile crisis workers to be credentialed in the ER and work with their own psychiatric backup to develop collaborative disposition plans with ER physicians and social workers. ERs also should have the capacity – as a crisis system partner, and in accordance with American College of Emergency Physician/American Association of Emergency Psychiatrists (ACEP/AAEP) guidelines – to initiate less urgent laboratory studies (e.g., urine drug screens, metabolic screens) that may be helpful for further behavioral health crisis evaluation and treatment, even though they may not be immediately needed for initial medical evaluation and disposition.

Behavioral health crisis consultation for medical/surgical inpatients

Another important component of an ideal crisis system is the ability to provide behavioral health crisis evaluation with psychiatric backup for medical/surgical inpatients. Common examples are individuals who are admitted medically after an overdose, self-inflicted injury, severe alcohol withdrawal, anorexic crisis or other medical/surgical issues that may need emergent intervention prior to specialized behavioral health treatment. In an ideal crisis system, the mobile crisis team, coordinated by the crisis hub, has the capacity and credentialing to evaluate individuals who are in medical/surgical units and coordinate transition to the appropriate component of the crisis continuum with the hospital’s attending physician and psychiatric consultant

General or psychiatric hospital-based inpatient treatment

One might initially imagine that inpatient psychiatric hospitalization would be unnecessary in an ideal crisis system. We might hope that if we had robust enough community services and seamless communication and transitions to those resources that everyone in crisis could be treated in the community and outside of the hospital setting. In fact, one measure of an inadequate crisis system is the overuse of inpatient hospitalization either because there aren’t adequate crisis and/or diversion services and/or there are not effective linkages to connect people to those services in real time.

Although the vision of no hospitalization is appealing, it does not comport with the natural history of the acute and severe illnesses people may be dealing with in a psychiatric and/or substance use disorder crisis. Inpatient hospital treatment is, and should remain, a critical part of the crisis response continuum. Whether in a locked or open unit, this is typically the most resource-intensive setting within the continuum. Typical psychiatric inpatient units for children, adolescents or adults are appropriate for patients who are acutely in need of close and continuous medical, nursing and staff intervention and National Council for Behavioral Health 117 monitoring over more than a 23-hour period, mostly for reasons involving safety, but also to treat individuals who may be psychiatrically acute and complex with medical comorbidities and/or may be resistant to participation in treatment. Hospitalization is also necessary for those for whom the safety risk remains unclear and when adequate evaluation or treatment cannot be achieved safely or effectively in a less intensive setting.

Specialty inpatient units

In addition to generic psychiatric inpatient units for adults, adolescents and children, there are populations that can benefit from specialized inpatient services. These include geriatric units that can safely treat older adults with medical and cognitive impairments, medical-psychiatric units that treat individuals of any age with combinations of acute psychiatric needs and acute medical illness and/or severe medical disability, eating disorder units, specialized units for co-occurring serious mental illness and addiction and specialized units for co-occurring psychiatric illness and intellectual/developmental disability or brain injury. In large urban areas, planning for specialized capacityshould be part of an ideal crisis system design.

In less populous areas, these types of specialized services may need to be planned as regional or even statewide tertiary care services. The ideal behavioral health crisis system needs to plan for how to respond to those individuals that present in local emergency rooms or crisis centers with these specialized needs, just as in emergency medical response systems. Individuals with specialized needs are often hardest to place from emergency rooms because psychiatric facilities reject them as too difficult. Purposeful planning can overcome this under the auspice of the accountable entity. Such planning may include financial and other incentives for local units to accept these patients to relieve pressure in the ER or crisis center, followed by planful transfer within a few days to an appropriate tertiary care facility if needed.

Do we need more psychiatric inpatient beds? In general, we don’t need more beds; we need a crisis system. However, the beds we have must be available geographically, including in more rural areas, and respond to the people who are most ill. Further, we may need more capacity to respond to people with higher acuity at the same time more people are diverted to residential crisis units and other crisis services.

An important challenge in defining the need for acute psychiatric hospitalization in an ideal crisis system is that there is a broad perception in most communities of too few beds (meaning psychiatric hospital beds) and a desire to invest in building inpatient hospital capacity for adults, older adults and children/youth. However, in a monograph entitled “Beyond Beds,” the National Association of State Mental Health Program Directors (NASMHPD) reports that the focus on inpatient beds is misleading (Pinals, Fuller, 2017).

Communities have an accurate perception of needing more for people in behavioral health crisis, but what they need is an ideal crisis continuum, not just costly inpatient beds. Further, in the previously cited Phoenix data from Crisis Now (page 52 in the first section), of all the people who presented with behavioral health crisis who need beds, only 20% of those who needed a bed and only 14% of total crisis presentations needed psychiatric inpatient care (LOCUS Level 6). The remaining 54% of the total needed crisis residential services (LOCUS Level 5). Maximizing capacity for diversion and step-down does not replace the need for inpatient care, but it substantially reduces the amount of inpatient capacity that is needed.

Finally, it is important to note that in some systems, the ideal location for the crisis hub or crisis center, as well as observation beds, crisis stabilization beds, urgent care centers, etc., may be on the campus of a psychiatric inpatient facility because of available space and proximity of nursing/medical back up. Note that the psychiatric inpatient unit should be regarded as a full partner/member in the continuum, not isolated from the rest of the continuum, and become a regular participant in community crisis collaborative planning.

Measurable Criteria for an Ideal System

The accountable entity works with its community crisis collaborative to include hospital partners and ensure implementation of the following capacities and processes across all ages and payer categories:

Strong collaborations with medical emergency rooms in the community

Each crisis center in the system has a formal collaboration agreement with a nearby ER to permit easy transfer back and forth to help clients quickly access the most appropriate setting.

The crisis system has clear protocols for medical screening that determine which levels of acuity can be managed in the crisis center and which require the ER, as well as utilizing ACEP/AAEM guidelines to define and streamline ER-based medical screening examinations, reduce unnecessary delays waiting for medical tests and offer helpful initiation of testing in the ER without waiting for results to facilitate treatment in a behavioral health setting that has less medical capability on-site.

There are protocols, memorandums of understanding and credentialing processes to permit mobile crisis evaluations in the ER and coordination between ER physicians and psychiatric providers in the crisis continuum.

ER clearance timeframes for behavioral health patients and ER boarding are monitored as overall system performance quality indicators, with the goal that no more than 1% of psychiatric patients going to the medical ER – whether adults or children – remain in the medical ER longer than 12 hours.

ERs develop formal training and protocols to respond in a welcoming, trauma-informed manner to individuals with mental health and/or SUD needs. De-escalation training is required and ERs monitor restraint episodes for continuous improvement and reduction.

Implementation of at least one psychiatric emergency service (e.g., EmPATH model) in a hospital emergency department.

Systems should implement EmPATH models or similar models for ER based psychiatric emergency services whenever feasible. Larger systems should have at least one designated tertiary psychiatric emergency room facility connected to one major ER. These programs should complement, not replace, the community-based crisis center.

Formal mechanisms to ensure crisis evaluation and coordination for individuals with acute behavioral health needs admitted to medical/surgical units

There are formal protocols for mobile crisis and the crisis center to collaborate with medical inpatient units and hospital-based psychiatric consultants to provide emergency behavioral health crisis evaluation, intervention and disposition for medical/surgical inpatients as indicated.

General hospital units have clear procedures and staff training for welcoming, safe, trauma-informed interventions (including withdrawal protocols) for individuals who present with acute behavioral health crisis as well as acute medical needs.

Adequate high quality psychiatric inpatient capacity for all age groups

There should be adequate psychiatric inpatient services for children, adolescents, adults and older adults with medical/cognitive needs. Adequacy requires bed availability within one-hour drive time of each crisis access center. Adequacy volume is based on planning based on expected utilization in the context of a full crisis continuum, including crisis residential services for step down and diversion. All payers should support the full continuum of services to prevent bed access limitations for uninsured or Medicaid clients, just as there is access for uninsured individuals to medical/surgery beds. Adequacy planning should expect bed utilization to be no less than 50% and no more than 95% for any age group and all beds in the community should be full no more than 5% of the days in any year.

Payment rates by all payers are no less than cost for hospitalization. There should not be a rate disparity between psychiatric acute inpatient care and medical/surgical inpatient care such that hospitals lose money on their psychiatric services.

There should be clear standards and criteria (based on LOCUS and CALOCUS, for example) about when inpatient hospitalization is medically necessary for both admission and continuing stay, as opposed to other levels of care in the continuum. Community inpatient units must be expected to accept involuntary patients on emergency or short-term holds, as opposed to all involuntary patients having to go to the state hospital; however, voluntary patients who meet medical necessity criteria should be accepted as well. Community inpatient units, whether hospital-based or free-standing, must welcome individuals who may have active substance use without arbitrary barriers to admission based on urine screens or blood alcohol level. Similarly, units must be able to accept any individual whose medical condition could be managed at home if psychiatric care wasn’t required, as well as otherwise appropriate individuals with any level of intellectual/cognitive disability who are capable of basic self-care.

The ideal crisis system and psychiatric inpatient facilities should make use and duration of involuntary legal status as little as possible. This is consistent with a patient-centered and empowered system culture. Incidence and duration of involuntary status should be measured and reported as a performance indicator.

Psychiatric inpatient facilities should be full partners in the crisis continuum and participants in the crisis collaborative that serves the community.

There should be adequately staffed, trauma-informed, recovery-oriented and co-occurring capable services offered on the inpatient units including:

• Adequate staff-to-patient staffing ratios for nurses, techs, peers, clinicians and psychiatric care providers with regularly planned interdisciplinary team meetings for comprehensive service planning in collaboration with patients and their collaterals. Treatment and treatment planning will be team based, patient/family-centered, trauma-informed and recovery-oriented with an emphasis on hope and resilience.
• Availability of crisis intervention, rehabilitation and other relevant psychotherapeutic interventions, both individual and group, provided by adequately trained staff who are appropriately supported with supervision, mentoring and quality improvement and adherence to evidence-based and evidence informed practice. Capacity to individualize services for those who may not be able to participate in groups.
• Availability of competent ancillary services in treatment such as well-trained and supported pharmacists, internal medicine providers, specialty medical consultation services, patient rights and privacy staff.
• Full inclusion of peers/people with lived experience in inpatient services as accepted members of the interdisciplinary team.
• Availability of, or access to, such best practices as electroconvulsive therapy, dialectical behavioral therapy and cognitive behavioral therapy.
• Robust use of measurement tools and data to evaluate the efficacy of both the treatment of individuals (e.g., outcome measures) and the collective work of inpatient units (e.g., acuity scales).
• Robust and competent leadership and oversight in order to appropriately lead efforts around continuous quality improvement, client experience, length of stay and quality of treatment. Many of these issues represent a tension between quality and necessarily limited resources and can only be navigated well in the context of strong leadership, which ideally is team-based and involves staff at all levels.
• Ongoing training and competencies to create a treatment environment that is welcoming, multidimensional, including integrative therapeutic modalities such as yoga, art and occupational therapy, and where clinicians are skilled and up- to-date on cultural dimensions to treatment including LGBTQI competency.
• A strong emphasis on reducing the use of seclusion and restraint and forced medications through such means as comfort rooms.
• There are expectations and protocols for regular communication between inpatient providers, the crisis hub/crisis tracking and community behavioral health providers immediately after admission, regularly during treatment and after discharge.
• Transition from inpatient to community (including crisis residential step-down) is expected to occur within three business days, not the Healthcare Effectiveness Data and Information Set standard of seven days, as three days have been demonstrated to have a meaningful impact on improving continuity of care.
• The accountable entity monitors inpatient access, utilization, transitions, collaboration, critical incidents, client satisfaction and quality of care as part of the overall quality assurance/performance improvement program, in collaboration with funders.
• A third option is to develop an urgent care component as part of a crisis hub or crisis access center. This permits the crisis center to provide safety-net backup for individuals at risk of decompensation due to urgent need for med refill or adjustment, for example, as well as provide quick warm handoff for crisis follow-up for individuals who need urgent ambulatory care, but do not immediately have connection to a routine community behavioral health provider.

Extended inpatient hospitalization and residential rehabilitation

Adequate access to acute inpatient hospitalization for children, adolescents, adults, and older adults who need the highest level of medically managed intervention is a critical feature of an ideal crisis system. Many communities experience a lack of adequate access to acute inpatient beds because the need for such services outstrips the available supply. An ideal crisis system provides a range of alternative responses that significantly limit the need for acute inpatient beds in any community, reducing demand by as much as 70%-85% compared to no such services (Pinals, Fuller, 2017). However, the presence or absence of a crisis system is not the only variable that contributes to adequate access to acute inpatient beds. One variable is whether payment rates by public and private insurers provide adequate reimbursement (compared to payment for medical acute services) that make such services financially viable for health systems or freestanding psychiatric hospitals (see Financing Section of this report). Another important variable is access to intermediate length of stay services for individuals who have persistent needs for high levels of intervention following their acute stay, and therefore cannot be quickly transitioned to appropriate community-based interventions. Examples may include extended inpatient hospitalization (as for individuals who have serious treatment refractory conditions) as well as extended residential psychiatric rehabilitation facilities (examples are Psychiatric Residential Treatment Facilities for children or adolescents, or specialized behavioral health capable nursing facilities for older adults). Even though the percentage of all acute admissions who may require these types of services is small, when these services are not adequately available in a state system, there is significant negative impact on acute bed availability, both because longer stay patients impede access through the front door and hospitals become more reluctant to accept admissions that might become a placement risk.

Discussion of access to extended inpatient hospitalization and residential rehabilitation facilities is beyond the scope of this report, but nonetheless is an important issue to acknowledge. As of this writing the American Psychiatric Association is engaged in creation of a model by which any community can calculate bed need by age and by acute vs. intermediate vs. long-term, based on both population characteristics and the degree to which an ideal crisis continuum and other community services are present.

• Intensive community-based crisis intervention: There are many individuals and families with complex challenges who present with an immediate crisis that needs urgent resolution (e.g., acute suicidality, psychosis), but who continue to need intensive intervention and support for an extended period of time following the initial crisis presentation. These may also include families with multiple problems whose situation remains unstable even after addressing the child’s acute need.
  For some of these adults or families, there will eventually be need for a long-term intensive community based service (LOCUS Level 4), such as ACT or wraparound, but for many of them, a shorter term of two weeks to three months of intensive community-based crisis intervention (also LOCUS Level 4), using evidence-based strategies such as critical time intervention, multisystemic therapy or functional family therapy for families will provide enough stability for clients to continue in ongoing care at lower intensity. These services are essential within the ideal crisis continuum because otherwise the individuals and families who need these services have difficulty making the transition from higher-end crisis intervention (e.g., crisis center, crisis bed, hospitalization) to more routine outpatient care and may cycle back into crisis or get into trouble in other areas (e.g., arrest, homeless, child welfare involvement). In some systems, there is provision for intensive outpatient crisis services in the form of partial hospitalization programs or mental health IOP group programs.
• Length of stay: All services can be provided for brief periods, ideally two weeks and up to a maximum of three months, during which time transition to continuing services at the right level of intensity can be arranged.