Why It Matters
Assigning a mental health clinician with problem-solving skills to the emergency department can help patients get the right behavioral health care more efficiently.
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Building Trust to Address Behavioral Health Needs in the Emergency Department

By IHI Multimedia Team | Tuesday, November 12, 2019

Jesse Radloff is a licensed mental health counselor (LMHC). In December of 2017, he joined the emergency department (ED) staff at Orlando Health South Seminole Hospital (SSEM), a 206-bed hospital near downtown Orlando. The hospital is also the home of Orlando Health’s 80-bed psychiatric hospital.

Radloff was hired in a new role: as an ED LMHC/Care Coordinator. He sits at the front of the nursing station facing the entrance to the ED, and he is charged with doing whatever he can to make sure behavioral health patients get what they need. As Radloff describes it, when patients arrive, he will “talk with them, get a sense of what’s going on with them, get telepsychiatry involved.” Since his role was brand-new when he started, it was something of an experiment to see exactly what it would entail. He started the job shortly before SSEM joined the ED & Upstream (ED & UP) Learning Community. Convened by IHI in partnership with Well Being Trust, the ED & UP Learning Community was a collection of health care teams working to improve patient outcomes, experience of care, and staff safety while also decreasing avoidable, repeat visits to the ED for individuals with mental health and substance abuse issues.

The addition — and continual evolution — of Radloff’s role formed a major part of SSEM’s work as part of ED & UP, along with related changes. For example, the team instituted a standard ED triage assessment. This assessment includes administration of the Columbia Suicide Severity Rating Scale and a mechanism to identify victims of human trafficking. Radloff is one of the staff members who administers it.

Prior to their participation in the Learning Community, South Seminole had established 24/7 access to telepsychiatry to determine whether patients should be admitted or referred elsewhere, and whether they need to start on medication. Only the ED doctors were allowed to determine whether someone was eligible to be evaluated by telepsychiatry. Recognizing that other staff members were capable of doing this assessment, and that sharing this responsibility would make the process more efficient, the team instituted a change. Now, Radloff and the psych triage nurses and another ED nurse can initiate telepsychiatry.

South Seminole had also already established an emPATH (emergency Psychiatric Assessment, Treatment & Healing) unit for ED behavioral health patients. This innovative intervention enables ED providers to triage and begin initial treatment for behavioral health patients in a special area of the ED with a calm and supportive atmosphere, away from the often-chaotic environment in the main part of the ED where medical patients are seen. Although Radloff spends most of his time in the main part of the ED, he sometimes checks in on patients on the emPATH unit.

During the Learning Community, a major aim of the team’s work was to improve the process of connecting patients with outside resources. In the past, patients were often discharged with little more than a list of numbers to call. Now, Radloff will meet with them (and, for adolescents, their parents). If the decision is made to discharge, “I’ll get to work trying to find someone in the community who can see them in a reasonable amount of time,” says Radloff. He has developed relationships with community clinics, and he tries to set patients up with an appointment, ideally before they leave.

LEARN MORE: IHI National Forum

For example, one day, a 16-year-old boy was brought in on involuntary status due to a school report of suicidal ideation. Radloff met with the boy, performed a psychosocial assessment, and recommended evaluation by telepsychiatry. The patient spoke with the telepsychiatrist, who then overturned the involuntary admission order, prescribed medication, and recommended outpatient follow-up. Radloff assisted his parents with scheduling an outpatient follow-up appointment before they left the ED.

Another important change is that Radloff started placing post-discharge calls, within two weeks, to all patients identified as having mental health concerns who were not admitted to inpatient care. “I give a phone call, follow up to see how they’re doing,” Radloff reports. “Were they successful in obtaining follow-up? If so, cool. If not, what happened? Do they want help?”

Radloff calls providers’ offices to confirm that they’re in the patient’s insurance network, knowing that he cannot necessarily rely on the information on websites: Sometimes he fields customer complaints, sometimes he receives compliments. “You never know how someone’s gonna be feeling on any given day,” he says. “Whatever comes up, if I can help them, I do.”

Over the course of the last 35 weeks, Radloff reached out to approximately 400 patients who presented to the ED with mental health concerns and were discharged without admission. Every week, he assisted at least one patient with obtaining mental health follow-up appointments and further support; sometimes he was able to help three or four.

During the Learning Community, Radloff was working five eight-hour shifts per week, from Saturday through Wednesday. SSEM is now expanding his position to cover seven days a week. They plan to hire a new staff member to cover his days off. After the initial challenge of getting the physicians to embrace his role, Radloff says, “Now when I take a few days off, it’s like, ‘Where have you been?’”

Editor’s note: The team from Orlando Health South Seminole Hospital and others will describe the work of the ED & UP Learning Community at the IHI National Forum during session SH19: EDs and Communities: Rethinking Behavioral Health Care on Sunday, December 8 from 1:00 to 4:30 PM.

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