Earlier this summer, senior leaders from six health systems gathered in Chicago for Vituity's second Behavioral Health Roundtable. The event brought together thought leaders from around the country to discuss issues and exchange ideas to improve care for acute and emergency behavioral health patients.
The Roundtable participants had much to talk about. Emergency departments (EDs) across the country are struggling to meet the growing demand for behavioral health care. At least one in eight ED visits now involves a mental health or substance abuse issue.
Of particular concern are ED visits following a suicide attempt, which rose 414 percent between 2006 and 2014. "Suicide rates are complicated by the opioid crisis," one participant noted. "In many cases, it's difficult to differentiate overdose deaths from suicide deaths."
Demand for care is further complicated by the fact that providers in many EDs have limited opportunities to consult with psychiatrists. Seventy-five percent of ED physicians report seeing patients at least once a shift who require hospitalization for psychiatric treatment. However, less than 20 percent of emergency physicians have access to a psychiatrist on call, according to ACEP’s 2016 Emergency Physician Poll.
The difficulty in caring for patients in behavioral health crisis has been exacerbated by a growing shortage of both psychiatrists and inpatient mental health facilities. The United States needs an additional 15,600 psychiatrists by 2025 to meet the demand for care. Meanwhile, the number of public inpatient psychiatric beds has declined by 17 percent since 2010.
The Roundtable participants discussed the social, operational, and financial determinants of the crisis. Additionally, many saw the rapidly evolving regulatory landscape compounding the challenges facing their hospitals. Here are some of the top issues they identified, with additional commentary by Vituity's Scott Zeller, MD, Vice President of Acute Psychiatry, and Herb Harman, MD, Associate Director of Telepsychiatry.
Many hospitals are surprised to learn that Centers for Medicare and Medicaid Services (CMS) has begun collecting ED length-of-stay (LOS) data for psychiatric/mental health patients. Data capture on Hospital Outpatient Quality Reporting Measure OP-18c started in October 2017. CMS will publicly report the initial results in late summer 2018.
The Inpatient Psychiatric Facility Quality Reporting (IPFQR) is a CMS quality program that monitors the performance of psychiatric hospitals and inpatient behavioral health units.
IPFQR introduced new measures for 2017–18 focused on improving transitions of care and preventing readmissions. Notable examples include:
The last measure is especially notable, because some behavioral health disorders carry very high readmission rates. For example, 22.7 percent of patients admitted with a psychotic disorder like schizophrenia return to the hospital within 30 days of discharge. Only congestive heart failure has a higher readmission rate.
The Merit-Based Incentive Payment System (MIPS) now governs reimbursement of physicians and groups. MIPS involves downside risk, and the percentage of Medicare income at risk increases each year. By 2020, 9 percent of MIPS Medicare payments will be at risk based on quality reporting and performance.
In 2017 and 2018, CMS introduced four new MIPS measures focused on transitions of care in psychiatry. They have also proposed removal of some psychiatric measures related to substance abuse and restraints. You can read more about latest psychiatry measure set here.
A Joint Commission technical advisory panel is considering whether all patients presenting to the ED should undergo suicide screening. (Current standards require screening for behavioral health patients only.)
Studies show that the majority of people who die by suicide visit the ED in the last six months of their lives. For this reason, many health systems (including some represented at the summit) have moved toward universal screening of patients.
However, expanding screening could also exacerbate existing supply and demand issues. "Emergency physicians are worried," Dr. Zeller says. "There are not enough behavioral health resources as is. Screening all patients, even those without behavioral health complaints, could hurt our ability to care for those with acute needs."
Current Joint Commissions suicide screening protocols classify patients as low, medium, or high risk. According to the guidelines, high-risk patients must be placed in "suicide safe" areas and monitored closely by staff.
However, these broad categories may not tell the whole story. "Some surveyors put more value on the risk category than on a full-page, comprehensive behavioral health evaluation," Dr. Harman says.
Participants also noted the limitations of existing suicide screening tools. "The Joint Commission is penalizing some hospitals for using their own tools and approaches rather than those prescribed as ‘preferred’ in the accreditation standards — even when the hospitals' screenings might be more personalized and patient-focused," Dr. Zeller says.
Hospitals, health systems, and individuals can help improve behavioral health regulations by participating in their professional organizations, commenting on forthcoming measures, and working directly with relevant agencies.
One participant described his hospital's efforts to engage community partners in care. "Housing resources in our area are fragmented, so we actually brought a developer on board and will be applying the assisted living model to healthcare," he said. "This will give us more continuity with medication management and follow-up care." The health system is also reaching out to community health workers and law enforcement to involve them in the project.
Mobilizing concerned community members can also be an avenue for change. "Behavioral health is always a popular recipient of philanthropy," one participant noted. "We have found that donors are touched by mental health."
Drs. Zeller and Harman shared the following example of how Vituity is working with regulators to improve behavioral health policy:
Dr. Zeller recently met with CMS officials in Baltimore to discuss reimbursement strategies for emergency psychiatry services in the acute care setting. Research shows that most psychiatric crises can be addressed within 24 hours, but our current systems of care and reimbursement mechanisms don’t align with this. When patients in psychiatric crisis are assessed and treated promptly in the ED (like other medical emergencies), discharge rates rise and outcomes improve.
For EDs without psychiatric coverage, telepsychiatry is often the fastest way to accomplish this goal. However, like many new or innovative solutions, reimbursement often lags. "Hospitals can get reimbursed if their state has parity laws, but it's difficult and varies by state," Zeller says. "Getting CMS to recognize a cost-effective way to reimburse psychiatric care may be my life's work."
Due to these limitations, many health systems invest in telepsychiatry programs not for direct revenue generation but because it is the right thing to do and because boarding psychiatric patients in the ED can be very expensive. Hospital leaders who have invested in these types of services say that the quality of care and efficiency improvements in their EDs outweigh investments in these types of services.
CMS officials told Zeller that in order to expand coverage of crisis reimbursement, they would need to see more data about outcomes and efficacy. This may represent an opportunity for health systems and government agencies to collaborate in the future.
While the current behavioral health regulations create challenges for hospitals and health systems, many Roundtable participants also shared innovative ways in which their systems were improving care. Among these solutions is the EmPATH Unit, Vituity's EMTALA-compliant alternative to ED boarding of behavioral health patients.
Chief among the many benefits of the EmPATH Unit is that it provides patients with immediate evaluation and treatment by a psychiatrist as well as a calming and comfortable setting distinct from the atmosphere of a typical ED. Dr. Zeller notes that, “The focus of EmPATH Units is on assessment and healing — putting the two together."
EmPATH Units also alleviate volume pressure in the ED, eliminate most ED psychiatric patient boarding, and lead to a dramatic reduction in psychiatric inpatient admission rates (up to 80 percent). Also, according to Dr. Zeller, “The EmPATH Unit does not negatively impact inpatient business but allows for more appropriate utilization of inpatient beds by vetting and admitting only those patients who truly need hospitalization, thus avoiding difficult one-day hospitalizations and payer admission denials."
In addition to being cost-effective, many organizations have found unused space in their facilities to develop one of these units. "We remodeled a pediatric unit to serve as our EmPATH Unit," one participant said.
New models of care are addressing the psychiatric burden on our nation’s EDs and changing the approach to assessing and treating patients experiencing a behavioral health emergency. As a result, hospitals have a significant opportunity to transform the healthcare experience of one of the most complex and underserved patient populations.
This can only happen through the integration of emergency and behavioral health services, formalized training and the addition of services such as telepsychiatry and crisis stabilization units like EmPATH into the acute care continuum to deliver patient-centric care and improved operations.
Vituity is committed to the transformation of acute psychiatry to ensure appropriate, timely, and compassionate care through proven, cost-effective methods. To learn more about how Vituity is leading the transformation of behavioral healthcare delivery, please visit us as at https://www.partnerwithvituity.com/redefining-ed-care.
We would like to thank the following health systems for participating in our 2018 Behavioral Health Executive Roundtable:
Originally published August 28, 2018.