2/8/2018 As emergency rooms fail in treating mental health, systems create new plans, centers | Healthcare Finance News

(http://oascentral.healthcare nancenews.com/RealMedia/ads/click_lx.ads/healthcare
x) nancenews.com/1153272741/Frame1/default/emp
REIMBURSEMENT (/RESOURCE-TOPIC/REIMBURSEMENT) REVENUE CYCLE MANAGEMENT (/RESOURCE-TOPIC/REVENUE-CYCLE-MANAGEMENT)

STRATEGIC PLANNING (/RESOURCE-TOPIC/STRATEGIC-PLANNING) CAPITAL FINANCE (/RESOURCE-TOPIC/CAPITAL-FINANCE)

news.com/RealMedia/ads/click_lx.ads/healthcare
SUPPLY CHAIN (/RESOURCE-TOPIC/SUPPLY-CHAIN) nancenews.com/1506396735/Position3/default/empty.gif/3741645a745670364945454
ACCOUNTING & FINANCIAL MANAGEMENT (/RESOURCE-TOPIC/ACCOUNTING-FINANCIAL-MANAGEMENT) MORE(http://oascent

x)

(http://oascentral.healthcare nancenews.com/RealMedia/ads/click_lx.ads/healthcare nancenews.com/L25/362938061/Top/Him

x)

Predictive CMS' Patrick Tracking 2017

analytics can Conway to healthcare
Top Stories spot patients head BCBS frauds
not taking their North Carolina
medicine (/news/patrick-conway- (/slideshow/biggest-
(/news/predictive-analytics- leaving-cms-head-blue-cross- healthcare-frauds-2017-
can-spot-patients-not-taking- blue-shield-north-carolina) running-list)
their-medicine)

APR 12, 2016 MORE ON POPULATION HEALTH (/RESOURCE-TOPIC/POPULATION-HEALTH)

As emergency rooms fail in treating

mental health, systems create new
plans, centers
Extended boarding in chaotic emergency departments detrimental
to patients and physicians, experts agree.

Beth Jones Sanborn (/news/author/90386), Managing Editor

(/news/author/90386)

Enloe Medical Center, a 298-bed standalone nonpro t hospital in Chico, California, is

the only voluntary acute care mental health program for adults north of Sacramento all
the way to the Oregon border.

More than 80 percent of emergency room physicians say the mental healthcare
systems in their regions are dysfunctional, and do not adequately serve patients,
according to a survey done in December by the American College of Emergency
Physicians involving 1,500 of its members.

Unfortunately, thousands of people in need of mental health treatment are often

being dropped at the emergency departments of their local hospitals, where
under federal law doctors must evaluate these patients despite the limitations on
ER-based mental health treatment.

http://www.healthcarefinancenews.com/news/emergency-rooms-fail-treating-mental-health-health-systems-create-new-treatment-plans 1/9
2/8/2018 As emergency rooms fail in treating mental health, systems create new plans, centers | Healthcare Finance News

"The patients are clearly not getting the best care available if they are sitting in
the emergency department for long periods of time." said Sandra Schneider, MD,
director of emergency medicine practice for ACEP. "One of the biggest problems
around psychiatric patients in the emergency department is that when we see a
patient with a psychiatric illness, there are very few resources for us in the
emergency department that are there on a 24/7 basis."

[Also: Even under parity rules, plans may charge higher specialty copays for
counseling (/news/even-under-parity-rules-plans-may-charge-higher-specialty-
copays-counseling)]

One thing the ACEP study discussed was a lack of tailored education and
training for dealing with mental health ER patients. It also pointed to data from
the National Alliance on Mental Illness that showed 38 percent of mental health
patients in the ER had waited more than 7 hours to see a mental health
professional. And in 21 percent of cases, the wait was more than 10 hours.
That's a long time in a hectic and stressful environment for someone who is
already in crisis.

It's complex problem that isn't going away. If anything, it's growing. According to
ACEP, one in 25 adults, or 13.6 million, experience a serious mental illness in any
given year that signi cantly impedes one or more "major life activities."

The roadblocks
Schneider, who is also a practicing emergency physician, said one of the biggest
challenges in dealing with mental health patients in the ER is after the initial
consultation or rst efforts at treatment. Doctors who are unsure whether that
patient requires further care or should be sent home don't have much of a
sounding board to work with because they lack instant access to a psychiatrist.

"If I had that same patient with an orthopedic injury or with a surgical injury, I can
pick up the phone and I can talk to another physician and describe the case, have
them look at the x-ray or the EKG, whatever, and they sometimes would even
come in and see the patient. If I have a patient with a psychiatric illness, in
general I can't get somebody. I might be able to get a social worker. I might be
able to get a nurse. When we did a recent survey, the vast majority of people
could not get a psychiatrist and could not talk to a psychiatrist about the patient."

That issue carries through to patients who might need outpatient care or just a
psychiatric follow-up once they leave. Schneider said the system is complicated,
and resources that are there one day are unavailable the next.

[Also: Bills hope to reverse a growing shortage of hospital beds for psychiatric
patients (/news/dearth-hospital-beds-patients-psychiatric-crisis)]

"I've talked with several psychiatrists who say they can't gure it out. So just
getting them to the next level of resource, the next follow-up is very dif cult."

Experts also say boarding can create a dilemma both for patient and the
hospital. Boarding is when patients are kept in the emergency department while
waiting for an inpatient bed, and most healthcare professionals agree it is
harmful to the patient.

If boarding is an issue among general medical patients, it is catastrophe when it

comes to mental health patients, Schneider said. According to the ACEP study,
70 percent of their physicians said they'd boarded a patient during their last shift
that was waiting for a mental health bed. Many of them had boarded for days,
even 10 days or more.

http://www.healthcarefinancenews.com/news/emergency-rooms-fail-treating-mental-health-health-systems-create-new-treatment-plans 2/9
2/8/2018 As emergency rooms fail in treating mental health, systems create new plans, centers | Healthcare Finance News

"Imagine you went to the hospital with appendicitis and it took 7 hours for you to
see a surgeon. No one in the world would say that was appropriate treatment
and yet that's what happens a lot in mental illness. No one is taking this as a
serious illness and a lot of it has to do with reimbursement. The reimbursement
(/directory/reimbursement) for taking care of mental health patients is poor."

In addition to the negative effect on a patient's health, there is enormous nancial

impact, too.

"The emergency department is like a restaurant. And if you have a restaurant that
is turning over tables, you're doing good business. If you have a bunch of
customers that would come in the morning for breakfast and never leave and
just sit at that table, you'd never be able to make money. And that is exactly
what's happening with the psychiatric patients when they're sitting in the
emergency department."

Schneider said it is also costly in terms of staff resources. For one thing, it is
required that a nurse supervise a mental health patient while they are in the ER,
which is called a one-to-one, to make sure they don't run away or hurt
themselves.

"You wouldn't see this at a psychiatric hospital but we have to do it because we're
not a psychiatric facility," said Schneider.

The behavioral health unit of Enloe Health.

Enloe's approach
Enloe Medical Center is a 298-bed standalone nonpro t hospital in Chico,
California. It is also home to the only voluntary acute care (/directory/acute-care)
mental health program for adults north of Sacramento all the way to the Oregon
border, according to CFO Myron Machula.

"We don't necessarily like that distinction, but there it is."

Enloe has run the Behavioral Health Unit  since 1998 after merging with
Community Hospital to become Enloe Medical Center. As part of that
transaction, they acquired the behavioral health program.

It's an unlocked unit separate from the medical center where mental health
patients from the community and the emergency department are referred for
treatment. It houses 30 licensed beds and discharges 750 to 800 patients
annually, about 10 per day. Machula estimates that about 20 percent of those
patients are coming from the emergency room. So, instead of boarding in the

http://www.healthcarefinancenews.com/news/emergency-rooms-fail-treating-mental-health-health-systems-create-new-treatment-plans 3/9
2/8/2018 As emergency rooms fail in treating mental health, systems create new plans, centers | Healthcare Finance News

emergency department for hours or days until they see a psychiatrist, mental
health patients are sent to the BHU, which is quieter, less chaotic, and more
suitable for their care.

Molly Schneider, an emergency physician at Enloe, said she sees at least one
mental health patient every day. Not only does the BHU offer a better
environment for them, it gets them started on treatment sooner and it opens up
beds for medical emergencies. While she admits it's not a perfect situation or
system, she pointed out that it is at a minimum a much-needed "release valve"
for what would otherwise be an overcrowded emergency department where
beds were taken up by mental health cases instead of the strokes, heart attacks
and other immediate needs that demand their attention as ER physicians.

"The behavioral health patients can get lost in the ED. You have a nurse that has
to look out for them but when she gets a person that is having a heart attack or
whatever she has to direct her attention to that individual. You want the
behavioral health patient to get the level of care they need ongoing. That's how
we got to what we do and we're very lucky that we have that pop-off valve."

Lucky, Molly Schneider said, because the 16-bed county facility is full more times
than not, so the patients that end up at Enloe wouldn't have anywhere else to go
if not for the BHU.

"As the government sponsored entities for housing mental health patients has
slowly gone away over the last many decades, mental health patients have
nowhere to go. Many of them are on the streets, many of them are in jail and we
in emergency medicine are sometimes the safety net for things in society that
don't go well, and that includes mental health," she said.

Beyond patient care, the BHU model also helps Enloe do better nancially
because they are able to see more patients. And for a stand-alone nonpro t
hospital, that's crucial. Machula said the BHU's operating costs total about ve to
six million a year; a staff ratio of one nurse to every six patients does make the
unit pricey to run. Machula said they just about break even.

"I'm not saying it saves a huge amount of money but it puts it in a context where
the care is correct. It's certainly not putting us at a deeper level of expense. This
indeed does offset a certain amount of cost. We're winning no matter which way
we go with this."

The Calming Labyrinth at Alameda's John George Courtyard gives patients a place
to walk, meditate or focus.

The Alameda model

http://www.healthcarefinancenews.com/news/emergency-rooms-fail-treating-mental-health-health-systems-create-new-treatment-plans 4/9
2/8/2018 As emergency rooms fail in treating mental health, systems create new plans, centers | Healthcare Finance News

"If you intervene promptly in an emergency setting you can usually stabilize a
psychiatric emergency in less than 24 hours and therefore avoid hospitalization
all together. It ends up costing less than the status quo of boarding to do this,
and then it ends up saving untold millions for every system by avoiding
unnecessary hospitalization. On top of it all, it's much much better for the
patients to get on-demand emergency care with proper personnel when they
need it, rather than just being put on a gurney in a back hallway and saying, 'We'll
nd something for you in the next couple days.'"

That philosophy is what drives Scott Zeller, MD, chief of psychiatric emergency
services for Alameda Health System in Oakland, California, and a former
president of the American Association for Emergency Psychiatry. After seeing
community after community dealing with rampant boarding issues, Zeller led a
study in 2014 on how to end the vicious cycle. What he found was having a
dedicated regional psychiatric emergency room reduced boarding times by over
80 percent compared to the rest of the state, and overall hospitalization by 76
percent, all for less cost.

Zeller said the Alameda process has run for 10 years now and is unique from
other programs. If police respond to a 911 call and nd they are dealing with a
psychiatric emergency, they immediately contact an EMS crew. Upon their arrival,
law enforcement hand over the reigns to them, at which point a medical
evaluation is performed to see if any medical services are needed or if the patient
is medically stable enough to go right to the county psychiatric emergency
services.

The criteria include no chest pain, no abdominal pain, patients have to be

conscious, can't be bleeding much, and vitals have to be within a reasonable
range.

"Psychiatric emergencies are de ned by federal EMTALA laws as medical

emergencies, equivalent to having a heart attack or being in a car accident. We
certainly don't have police transport heart attacks or car accidents so why are we
doing that with psychiatric patients? It's also very stigmatizing for a psychiatric
patient," Zeller said.

Zeller says roughly two-thirds of those on psychiatric hold will be cleared to go

right to the county psych ER, and therefore never even see a hospital or take up
an emergency department bed.

Like Healthcare Finance on Facebook

(https://www.facebook.com/HealthcareFinanceNews)

Those that do need medical treatment rst are taken to the nearest ER, treated
and then cleared for transport to the psych ER, which is centrally located in
Alameda County. Zeller said ambulance crews have less than a 20-minute
turnaround in transporting patients to the psych ER and getting back out in the
eld.

"Essentially, there's no such thing as boarding in our county. The time it takes for
somebody to get from their ER to us once they're considered medically cleared is
just the time it takes for them to arrange transportation," Zeller said.

While he knows his exact model won't work for every system, the philosophy
behind it is what's key to more successful treatment of mental health
emergencies: the majority of psychiatric patients can have their emergency
condition resolved in less than 24 hours if you start treatment right away.

"Get people into the right place, at the right time with the right personnel. If you
do that, no matter how you adapt your model, you have a great chance of getting
the great majority of people the help they need and getting them somewhere
http://www.healthcarefinancenews.com/news/emergency-rooms-fail-treating-mental-health-health-systems-create-new-treatment-plans 5/9
2/8/2018 As emergency rooms fail in treating mental health, systems create new plans, centers | Healthcare Finance News

outside of the hospital much more quickly," Zeller said.

Twitter: @BethJSanborn (https://twitter.com/bethjsanborn)

Show All Comments

News

Once-failing hospitals say Healthcare mergers and Ana

accountability, transparency key acquisitions in 2016: Running list hea
to surviving fallout from failing (/slideshow/healthcare-mergers-and- data
patient safety grades acquisitions-2016-running-list) (/new
(/news/once-failing-hospitals-say- While 2015 was a record-breaking year in heal
accountability-and-transparency-key- healthcare mergers and acquisitions, 2016 Pam
saw more change as organizations across subs
surviving-fallout-failing) the industry adjust and adapt to the much
When Leapfrog released their Spring 2016 evolving nancial landscape.
emer
patient safety grades recently, 15 hospitals
is a w
got slapped with a very public 'F' grade
casting a spotlight on them that no
institution wants. ...

Whitepapers

Credible, Defensible Estimates Clinical Quality Measures 101Gain

(http://pages.healthcareitnews.com/Credible- Fina
(http://pages.healthcareitnews.com/Clinica
Defensible-Estimates.html? Quality-Measures-101.html? Imp
topic=revcycle) topic=revcycle%26budgeting%26capital
(http
na
In healthcare, every interaction with the Although quality-reporting programs such
Actio
patient matters. Especially in today’s as meaningful use provide incentives to
Syste
environment of continuous improvement, help providers implement and use
Reve
efforts have been concentrated on electronic health records (EHRs) to collect
Hosp
coordination among providers, the patient and report on clinical data, practices often
lookin
care experience and quality outcomes – all need help deciding what data to collect,
collec
laudable goals. which measures to report ...
ef cie
mark
to tur

http://www.healthcarefinancenews.com/news/emergency-rooms-fail-treating-mental-health-health-systems-create-new-treatment-plans 6/9
2/8/2018 As emergency rooms fail in treating mental health, systems create new plans, centers | Healthcare Finance News

(http://oascentral.healthcare nancene
x)

Breaking News. In-Depth

Reporting. Best Practices.
Delivered to your inbox daily.

Enter Your Email

Sign me up

(http://pages.healthcare nancenews.com/hfn-

newsletter-subscription.html)

Featured Resources

Debunk the Myth: Outsourcing Doesn't

Mean Losing Control

http://www.healthcarefinancenews.com/news/emergency-rooms-fail-treating-mental-health-health-systems-create-new-treatment-plans 7/9
2/8/2018 As emergency rooms fail in treating mental health, systems create new plans, centers | Healthcare Finance News

(http://pages.healthcare nancenews.c
the-myth-Outsourcing-doesnt-mean-
losing-control.html?
topic=accounting%2C%20 nancial%2C
With shifts in payer mixes and
reimbursement structure, the margin of
reimbursement has been shrinking steadily
over the last ve years. How do revenue
cycle leaders navigate payment reform
while maintaining stable business of ce
operations?

MostPopular

Top 10
healthcare
issues to watch
in 2016 (/news/top-10-
healthcare-issues-watch-
2016)

CMS cancels
mandatory
bundles, reduces
joint model participation
(/news/cms-cancels-
mandatory-episode-payment-
models-cuts-half-
participation-joint-
replacement-model)

Docs must now

explain
'observational'
statuses (/news/new-law-
mandates-doctors-tell-
medicare-patients-about-
observational-status)

List: 769
hospitals ned
for medical
errors, infections (/news/list-
769-hospitals- ned-medical-
errors-infections-cms)

http://www.healthcarefinancenews.com/news/emergency-rooms-fail-treating-mental-health-health-systems-create-new-treatment-plans 8/9
2/8/2018 As emergency rooms fail in treating mental health, systems create new plans, centers | Healthcare Finance News

http://www.healthcarefinancenews.com/news/emergency-rooms-fail-treating-mental-health-health-systems-create-new-treatment-plans 9/9