It’s well-recognized by emergency care practitioners that emergency psychiatric patients (EPPS) presenting with psychiatric-related complaints can often wait for hours—and sometimes days—to be seen by a clinician specially trained to provide definitive psychiatric evaluation and treatment. This lack of access not only results in suboptimal evaluation and treatment for this cohort, it also creates unnecessary emergency department crowding and delays care for all patients. In addition, the busy, anxiety-provoking emergency department environment can exacerbate the conditions of this patient population.

Current experience suggests that up to 75 percent of psychiatric patients on an ED hold can be discharged without in-patient admission.¹ Having appropriate psychiatric emergency services available not only improves care and decreases ED crowding, it significantly unburdens our already taxed in-patient psychiatric patient services.

The CSU Option

Crisis Stabilization Units (CSUs) provide intensive mental health crisis services to ED patients with psychiatric conditions who would otherwise have lengthy ED stays and/or be unnecessarily hospitalized. CSUs are an effective option for a variety of ED patients with psychiatric complaints, including repetitive users of emergency and inpatient psychiatric services, those with co-occurring substance abuse disorders, those needing emergent psychiatric medication management, and those whose presenting problems could be met with short-term (less than 24 hours) immediate psychiatric care and linkage to community-based resources.

CSUs provide crisis intervention services, including integrated services for co-occurring substance abuse disorders. They focus on recovery and linkage to ongoing community services and support and are designed to impact unnecessary and lengthy involuntary inpatient treatment, promoting care in voluntary recovery-oriented treatment settings.

To respond to patient needs, CEP America is partnering with hospitals and communities throughout the nation to co-create psychiatric emergency services (PES)/CSU models to meet the needs of the population and community. The program is pursuing two options to meet the needs of ED patients with psychiatric emergency conditions:
1. PES/CSU units attached to an acute care facility. This model allows for efficient medical clearance within the emergency department, transporting the patient to the PES/CSU afterward. It supports safe patient care delivery, meeting Emergency Medical Treatment and Labor Act (EMTALA) requirements.

2. Freestanding PES/CSU units. Partnerships with medical emergency departments are established to promote rapid access for patients requiring further medical stabilization.

Both models designate the psychiatric provider as the initial patient contact, providing the emergent psychiatric assessment and treatment initiation. When clinically indicated, medications are ordered in response to a patient’s needs. Upon completion of the assessment, patients enter into the therapeutic milieu, a healing environment staffed by psychiatric professionals.

During their stay in the PES/CSU, patients work directly with psychiatric care coordinators to facilitate outpatient support services to promote wellness and develop a crisis plan. When possible, families are included in the treatment planning process. Peer support roles within the milieu are also recommended as an additional resource to promote patient healing. Telepsychiatry expertise is also used in some models, allowing for psychiatric evaluations, medication management and treatment planning to be provided to remote locations and/or supplement provider access for models with high patient volume.

The operational and financial structure of PES/CSU models will vary to meet the needs of the population served. Developing the appropriate model type and size requires all key stakeholders to be involved, including initial involvement with counties, states, and private insurers to determine funding options—cost avoidance, reduction of unnecessary inpatient admissions, and providing patient care in the least-restrictive setting are areas of interest. Most Medicaid models include a code allowing for bundled payment reimbursement for emergency psychiatric services.

A Smart Solution

The results associated with patient care delivered in a PES/CSU setting shows that 68 to 70 percent of patients are discharged back to their community within 15 to 18 hours. This shift in provision of care at the least-restrictive level (ie, right care/right place/right time) allows for increased inpatient bed capacity for patients requiring inpatient treatment. Additionally, treatment for patients requiring inpatient care is initiated the PES/CSU setting, and inpatient admission criteria has been established, helping to reduce the frequency of payer denials. Treatment initiation in the PES/CSU setting can contribute to a reduced length of stay in the inpatient setting, resulting in efficient care and cost savings.

The national volume of patients requiring emergent psychiatric expertise continues to increase. In an effort to effectively meet the emergent clinical needs of these patients, boarding in medical emergency departments must be reduced. CEP America continues to expand efforts to create PES/CSU models within communities to enhance the availability of psychiatric emergency services. The ultimate goals are to provide excellent patient care delivery in a setting conducive to healing, and promoting care coordination in the least-restrictive environment, resulting in improved patient outcomes.

Dr. Tom is chief medical officer at CEP America. He completed his residency in Emergency Medicine at Johns Hopkins Hospital, and was a Kaiser Fellow at the Massachusetts Institute of Technology.

References

1. Zeller, S., Calma, ,N., Stone, A.  Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments.  West J Emerg Med. 2014 Feb; 15(1): 1–6.