It may seem counterintuitive.

“An emergency department (ED) is set up to do things rapidly,” says Chris Bouneff, Executive Director at the National Alliance on Mental Illness (NAMI) Chapter in Oregon. “But EDs need to slow down and be deliberate to make changes in the way they address mental health.”

Bouneff has been in his role for nine years at the grassroots organization that is dedicated to improving the quality of life for individuals — and their families and loved ones — living with mental illness. He and his team have worked with dozens of organizations and EDs — large and small, rural and urban — to improve the way they care for individuals with mental health needs.

Bouneff is also faculty for a new Learning Community, convened by IHI and Well Being Trust, comprising a small group of pioneering US hospitals and health systems that is working together for the next 18 months to improve the system of care for patients with mental health needs within the ED. More specifically, the aim of the Emergency Department and Upstream (ED & UP) Learning Community is for participating teams to improve patient outcomes and experience of care and staff safety while also decreasing avoidable, repeat visits to the ED for individuals with mental health and substance abuse issues.

We reached out to Bouneff to get his insights on some effective strategies EDs can use to improve the way they engage patients and families when responding to mental health crises. Here’s an edited version of our interview:

What can an ED do to start improving the way they treat patients and families who are dealing with a mental health crisis?

That’s like the $64,000 question. From what we’ve seen, EDs have the most success if they address this deliberately. It’s not enough to dance around the margins. It's not enough to acknowledge that there’s a problem. This requires a different kind of response. EDs need to slow down and be deliberate.

Once an ED has decided it wants to spend time on this, what are the steps to get started?

A good first step is to walk through how they are responding to these mental health crises now and how that’s failing. Map out the current experience and figure out where the gaps are. And it’s important to engage patients and families and determine what happened in the past — what went well, what didn’t go well. EDs need to rethink, completely, the way they respond to people appearing in crisis. It’s a task that requires commitment.

Can you say a bit more about the importance of engaging patients and families in the process?

I’m a huge believer that if an ED is going to commit to something like this, the customer needs to be at the heart of it. Customer might seem like an odd word to use, but this is a retail transaction. Health care is a business serving customers. So, in this case, how can you walk people through your process and gain that customer feedback? [Treating mental health crises] isn’t what EDs were set up to do, so if people are going to fundamentally change, they need to engage patients and families at some level.

Can you give an example of a traditional response to a patient dealing with a mental health crisis and then a more forward-thinking response?

Let’s say there’s a young adult in his 20s living with his parents who has just attempted suicide — he swallowed a lot of pills from his house. A traditional ED response, the intervention, is to medically stabilize the patient and then discharge. At that point, the parents are probably thinking, ‘What do you mean discharge?’ You are sending this person and family back home ill-equipped to handle next steps. Where you see success in an ED is when it’s more than just a medical stabilization. They collect history, understand behavioral health issues and needs, and then start thinking about the release plan. What resources should someone be tied to? What instructions do parents need to keep supporting their loved ones? What do parents need to keep an eye on that might require some response? EDs that are having more success have a more predictable behavioral intervention process. They are slowing down, calming the environment, and being more deliberate in dialogue with the patient and their network.

Can you share some examples of interventions you’ve seen that work well?

Yes, some EDs are doing some interesting stuff. For example, some EDs are contracting with suicide hotlines who provide follow-up phone calls after an ED visit, an intervention known as “caring contacts.” These suicide-prevention programs are showing tremendous promise for keeping people engaged until they can make their next appointment post-ED. It’s a low-intensity intervention. But, again, an ED can only come up with those interventions if they stop and look at the current process.

And in terms of resources, there are many community-based organizations out there. Experts at these organizations may not have academic credentials that we often seek, but accumulation of knowledge is a golden resource to be tapped. Do EDs know the local AA (Alcoholics Anonymous) or NA (Narcotics Anonymous) chapters? Or substance abuse organizations? Do they have NAMI chapters around them? There’s a demand for health care organizations to know more about their communities, and that need is only going to grow over time.

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In your experience, what are some pitfalls EDs should avoid when doing this work?

These efforts can fall down for the same reasons that plague efforts at any organization — jumping from one problem to the next and not really solving the issue. People focus on the problem of the day and work on that until the next problem of the day arises. They never complete fundamental work on the first problem, and something like this takes commitment. Also, some ED providers don’t see behavioral health as their role. You run into some training and cultural barriers.

How can you overcome those training and cultural barriers?  

As I mentioned, sitting down in some formal fashion and being deliberate about changing this. And starting to collect narratives, which can slowly change mindsets. Stories can mean more than raw data. People don’t get into health care to provide bad care. Once you start hearing about specific patient and family experiences, it has a profound impact on the empathy that drives people in health care. When people share narratives, they begin to see some changes. 

Any closing thoughts? What’s the lasting message you’d leave with readers?

It seems antithetical to how EDs operate — which is why it can seem imposing to make changes to the way they treat patients in a mental health crisis — but when we hear about positive experiences, it’s because an ED moved from a sprint to mid-distance running. It’s like a 100-meter dash versus a 3,000-meter run. Slowing down gives you a greater opportunity to gather more information, engage with patients and families, and improve your processes.

Mike Briddon is IHI Editorial Director. To learn more about the ED&UP work, we invite you to explore the IHI Innovation Report: Integrating Behavioral Health in the Emergency Department and Upstream.