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Simply working harder will not address the challenges of improving behavioral health care in the emergency department (ED) — system-level changes are needed. To develop solutions, IHI, in partnership with Well Being Trust, convened eight US hospitals in the Integrating Behavioral Health in the Emergency Department and Upstream (ED & UP) Learning Community. The initiative’s aim was to improve patient outcomes and experience of care and staff safety while decreasing avoidable repeat ED visits for individuals with mental health and substance use disorder issues.
The following excerpt from the Improving Behavioral Health Care in the Emergency Department and Upstream white paper shares the four key elements for improvement that emerged from the experience of the ED & UP Learning Community participants.
Culture Change Is at the Heart of Real Progress
Culture change in the ED is fundamental for improving care for individuals with mental health conditions and substance use disorders, including four key factors: manage patients presenting with an acute event using similar ED processes for triage and care of other medical conditions; equip ED teams to provide trauma-informed care; incorporate the patient perspective into improvements; and seek opportunities to reduce stigma and inequities.
This cultural shift is supported by the Emergency Medical Treatment and Labor Act (EMTALA) guidelines that define psychiatric emergencies presenting to the ED as medical emergencies, thus requiring the same obligations: 1) a medical screening examination by a licensed independent practitioner to determine if an emergency medical condition exists; 2) if an emergency medical condition exists, the ED must attempt to treat/stabilize the condition within its capacity and capability; and 3) if unable to stabilize, the ED must either admit to inpatient or transfer to another facility with the capacity and capability to stabilize the condition.
This is a significant shift in approach from “sedate and wait” (for an admission or transfer) to “triage, assess, and initiate treatment” within the ED whenever possible. Teams in the Learning Community tested this trauma-informed care approach by providing training and ongoing support for ED care teams as they made changes in practice during patient care encounters.
Changing ED culture and care delivery for individuals with mental health conditions and substance use disorders also requires incorporating the patient and family perspective on the ED care experience. Figure 1 illustrates a patient-centered perspective on a traditional ED patient flow process: entry, triage and assessment, initial treatment, and disposition (discharge, admission, or transfer to the next level of support).
Figure 1: Patient-Centered Perspective of the ED Care Experience for Individuals with Mental Health Conditions and Substance Use Disorders
Closely related to building a trauma-informed culture is acknowledging, identifying, and eliminating inequities in the care system for mental health conditions and substance use disorders. For this population, care is often either inaccessible or inadequate to address immediate and long-term needs. However, the challenges for those living with mental health conditions and substance use disorders are often compounded by issues of race, gender, age, sexual orientation, Zip code locations, payer status, and other identifying characteristics.
It is necessary to view the work through an equity lens to fully understand trauma and its effects on individuals and populations. Exposing and addressing issues of stigma associated with behavioral health issues, unequal treatment, bias, and institutional forms of racism and discrimination are central to improving care for this population.
Senior Leadership Actions Support and Promote Improvement
To fully test and implement changes that could really have an impact on patients, families, and ED staff, Learning Community teams recognized the need for support from their hospital and health system leaders. Each team had a designated senior sponsor who met regularly with the team, helped them stay on track, addressed organizational issues that presented challenges, and were especially helpful in making connections with community-based providers and organizations.
It is the responsibility of hospital leaders to ensure adequate resources for ED staff, including consultation, mechanisms for rapid follow-up appointments, physical facilities in the ED, and staff support.
Clinical and administrative leaders played key roles in supporting and guiding the Learning Community ED teams, including the following:
Showcased and built support for the work (e.g., attended Learning Community kickoff events, invited the ED team to present to senior leaders, discussed the work in system-level meetings);
Supported the ED improvement team (e.g., engaged in weekly touchpoints, attended team meetings, identified tools and resources, helped prioritize change ideas to test based on what was both strategic and feasible for the hospital and the ED team, ensured operational barriers were removed);
Connected with external partners (e.g., negotiated with managed care providers, supported meetings with and an open house for community-based partner organizations, explored ways to connect community organizations through electronic data sharing);
Built sustainability for the work (e.g., negotiated solutions for crisis/linkage services to be reimbursable, supported the addition of psychiatrists to clinical leadership, assisted with obtaining philanthropic funding for trauma-informed care training); and
Led plans to expand the work, including how to share lessons learned and spread improvements throughout the health system.
An Optimal Care System Spans Hospital and Community Services
Individuals with mental health conditions and substance use disorders and their families need one system of care that provides compassionate, coordinated, and easily accessible assistance seamlessly between community and hospital settings. The framework component, focused on strengthening relationships with community partners, was a unique aspect of the Learning Community, providing specific improvement ideas to help ED teams build connections and coordinate services for this population. Learning Community ED teams, often with assistance from hospital leaders, worked to reinforce existing partnerships with providers and community agencies in addition to building new partnerships based on patient needs.
A promising area for hospitals to further explore is leveraging population health initiatives to strengthen existing partnerships and increase the type and number of community partners. Hospitals can play an important role, together with their community partners, to advocate for changes in local systems of care, including expanding available resources as needed.
Demonstrate Impact with Both Stories and Data
Based on data collected by participating teams over the course of the 18-month Learning Community, some promising early results include reduced ED revisits within seven days, reduced ED length of stay, and a reduction in the number of patient-to-staff assaults and use of restraints. In addition to collecting data, teams also collected stories about the impact the changes they tested had on patients, families, and staff (see the accompanying improvement stories). Stories in combination with data demonstrate the full impact of the work, reflecting both the “head” and the “heart” of the teams themselves.
While process improvements and system-level changes are both needed to organize people and resources, it is the creation of a culture of caring that will drive continued change and improvement. This is perhaps the most important insight from the Learning Community.
Editor’s note: For more on this topic — including practical tips and tools — download the full Improving Behavioral Health Care in the Emergency Department and Upstream white paper.