When a child is in crisis, a parent's world telescopes into the sharpest focus: all that matters is helping relieve my child's suffering, right now. When that child's pain is caused by depression, anxiety, or suicidal thoughts, a parent's best recourse can be the emergency department (ED) of the local hospital.
As a parent myself, I am thrilled to see the creative work happening in EDs to support people in some of the most challenging moments of their lives. As a faculty member within the ED and Upstream Learning Community at IHI, two innovative approaches — one aimed at children and one aimed at adult patients — have caught my attention.
In Queens, New York, Cohen Children's Medical Center's (CCMC) Psychiatric Emergency Department is supporting children and families in their most challenging moments, aiming to help them weather the next storm. In Longwood, Florida, Orlando Health South Seminole Hospital is providing immediate mental health care in the emergency department. Both hospitals have realized that effective emergency care hinges on coordination with community-based care to support patient's health once the immediate crisis is resolved. And as participants in the ED & Upstream Learning Community — 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 — these hospitals are continually testing new approaches to connect people to community-based care to support their ongoing health.
Supporting Children at CCMC
CCMC's Pediatric Emergency Psychiatry Department believes that to achieve the Triple Aim — that is, to simultaneously improve children's health outcomes, families’ experience of the care, and limit health care costs — they need to collaborate with other organizations who support children’s healthy development.
Dr. Vera Feuer, the director of the Pediatric Emergency Psychiatry and Behavioral Urgent Health Care, recognizes that while children may interact with the hospital a few times per year, they participate in school nearly every day. And that means that the local schools are a natural partner to the ED in helping to keep children well and healthy. CCMC has met with multiple school districts to support schools to refer children to CCMC's care through a smooth and simple process.
“It’s always been really apparent to me that the reason the ED visit is not helpful is because of the lack of connection: every system operates in silos, no one connects,” says Feuer. “By working together with the pediatricians where the kids are going for care and the schools where they spend their days — by breaking down silos — we can help kids, and they won't need the ED anymore because they'll be better.”
Children and their parents need more than school resources, so Feuer and her team are also working to broker new partnerships to strengthen the support families have in the community. The team developed a simple referral process with local pediatricians and outpatient mental health care providers, building a system that allows quick communication between the ED and community providers.
Feuer continues to fill her calendar with community coalitions, public health events, and gatherings around children's activities. That initiative, curiosity, and openness has fostered important connections that have changed the way care is delivered at the organization. Children and their families are enjoying better connections to the community: in March, 73 percent of families were linked to community supports, up from an average of 43 percent in the winter months. Similarly, the number of families that the social work team was able to reach after discharge climbed from 42 percent in February to 61 percent in March, after the team identified streamlined processes.
Coordinating Care at South Seminole
In Longwood, Florida, Orlando Health South Seminole Hospital's Emergency Department has started weaving real-time mental health interventions into the usual care for their adult patients. One hire, made 18 months ago, was the catalyst for the change.
In late 2017, South Seminole's care management department hired Jesse Radloff, a licensed mental health counselor to serve as a care coordinator in the ED. From triage through discharge and beyond, care coordination shapes each patient's care journey. Radloff performs psychiatric triage, offers face-to-face mental health counseling in the ED, assesses patients' psychosocial needs, and identifies effective interventions to meet those needs. Often, he can divert individuals from an unnecessary inpatient stay by homing in on specific treatment needs and connecting patients to community-based care, allowing them to return home with full access to needed support.
Upon discharge from the ED, Radloff strives to provide each patient with a schedule of follow-up appointments that are tailored to their needs, preferences, and insurance coverage. Then, within two weeks of leaving the ED, each patient receives a check-in call about follow-up care and any potentially urgent needs. Any concerns are then elevated to crisis care or the ED director.
“We don’t view people as no longer in our care after they're discharged,” Radloff says. “I value the opportunity to assist our patients when they are in crisis, to be supportive of them, and to connect them to resources in community. I do everything I can to make sure they're treated holistically.”
People visiting the ED are getting the benefit of this holistic approach. For example, recently, a young woman was brought to the ED by law enforcement on an involuntary admission for psychiatric evaluation. Radloff completed the initial triage psychiatric assessment and considered that the involuntary order was probably unnecessary. While the young woman was being evaluated by telepsychiatry (they agreed that the involuntary hold was unnecessary), Radloff was able to schedule an outpatient psychiatry appointment for her a few days later. The young woman was able to go home with a referral in hand, avoiding an unnecessary stay in the inpatient unit.
Providing holistic, integrated mental health care in the ED does more than support positive health outcomes for the individual patient. The ED care team — psychiatric nurses, triage workers, and chart nurses — functions better through Radloff’s work. Radloff has become a trusted ear for the team and has an acute ability to look for signs of stress in patients (and providers) he sees every day.
To me, what's remarkable in these examples is that these EDs see their work as broader and deeper than offering a rapid and thorough care response to an immediate problem. These leaders and their teams understand that while someone may recover from an immediate crisis, that person — child or adult — and their family will need ongoing support to foster health over time.
Catherine Craig is faculty for the ED and Upstream (ED&UP) Learning Community.
You may also be interested in:
IHI Innovation Report — Integrating Behavioral Health in the Emergency Department and Upstream
3 Ways to Improve Behavioral Health in the Emergency Department