On the front lines of mental health care, emergency rooms are adapting

Patients seeking mental health care, sitting in emergency rooms for hours as clinical staff conduct physical tests unrelated to their problem. Case managers making scores of phone calls just to find one spot in an in-patient program.

This scenario encountered by mental health patients in their local emergency rooms is less than ideal, experts say, and is even more of a problem as hospitals see an influx of mental health patients, driven by scarce local resources for treatment and a national shortage of psychiatrists.

Noticing a trend of more psychiatric patients coming through emergency room doors, area hospitals have started to revamp how they treat mental health in emergency departments.

Staff members working in one Chicago area hospital system—Amita Health—are piloting a program at four of its emergency departments to more swiftly deliver treatment for psych patients while also reducing wait times and return visits.

The move represents one way hospitals across Chicago and the country are adjusting to a cultural shift in care due to an increase in mental health patients in emergency rooms, said Chris Novak, vice president and chief operating officer for Amita Health’s behavioral medicine service line.

“Unfortunately (emergency departments) have become the front door for behavioral health care,” he said, adding that those who visit emergency rooms more frequently often do so because they have no other way to access care, and aren’t necessarily in crisis or having a life-threatening emergency.

Dr. Vidor Friedman, president of the American College of Emergency Physicians, said hospital emergency rooms are often on the front lines of mental health care because there aren’t enough psychiatric resources to go around.

“This is not a new problem. It’s just a problem that hasn’t gone away,” he said.

In Chicago, advocates continue to balk at the 2012 decision of then-Mayor Rahm Emanuel to shutter six mental health clinics. Mayor Lori Lightfoot recently announced a funding increase for existing mental health resources rather than reopening the clinics, drawing further criticism.

In the absence of more local community solutions, patients sometimes have no choice but to visit their local ER, doctors say.

“When psych patients come to the emergency department, there’s a range … from “I want to hurt myself today’ to “I’m feeling very anxious and I need someone to talk to about those things,” ” said Dr. Meg Stahulak, emergency department medical director at Amita Health St. Joseph Medical Center in Lakeview—one of the sites piloting Amita’s new program. “In the past … pretty much everyone was treated the same.”

That meant requiring blood draws and other procedures that aren’t always needed for someone experiencing a lower-risk mental health problem, she said, which only adds to wait times and delays care.

The new program, an assessment tool called Emergency Psychiatric Intervention, or EPI, was developed by the company Vituity, which staffs the physicians working at Amita Health hospitals.

The tool, Stahulak said, provides emergency room staff with a way to better assess psychiatric patients. Staff began using it earlier this year at St. Joseph’s in Lakeview, as well as Saints Mary and Elizabeth Medical Center in West Town, Mercy Medical Center in Aurora and St. Francis Hospital in Evanston, but it could expand to other Amita hospitals in the future, she said.

The assessment allows lower-risk patients to bypass unnecessary steps in the ER, like bloodwork, which leads to a swifter discharge, Stahulak said. But before they leave, patients receive referrals to outpatient mental health care, as well as refills on prescriptions, if needed. This frees up time for staff to treat moderate and high-risk patients, who may need in-patient treatment, she said.

Amita also streamlined the way staff members find a spot in one of its 12 in-patient psychiatric programs by creating a centralized logistics center, so “emergency rooms can make one phone call instead of 12 phone calls,” Novak said.

Whether a patient needs an outpatient referral or placement in an inpatient program, the less time spent in the emergency department, the better, he said.

“From a behavioral health standpoint, the emergency department is not the most conducive environment,” Novak said. “It’s a busy, fast-paced environment, an anxious place to be. The goal is to get them moved from that … as quickly as possible.”

After several months of using the new tool, average wait times for lower-risk patients were cut by 40%, and patients who were assessed using the tool also had yet to revisit the hospital, he said, adding that recidivism often can be high among psych patients.

With the Centers for Disease Control and Prevention reporting climbing suicide rates, Novak said the improved efficiency is one example of how emergency staff members at many hospitals now think about mental health—that they should treat psychiatric issues “with the same urgency and sensitivity as someone who’s come in from a car crash.”

Northwestern Medicine Lake Forest Hospital earlier this month launched a new “telepsych” program after noticing an increase in emergency patients experiencing a mental health crisis, said Patti Gobel, a social worker and manager of the case management department.

Because the hospital does not have a behavioral health unit in the building, there’s not always a psychiatrist available on-site for a live consultation. Now the new telepsych option allows patients to conduct a video chat on an iPad with a psychiatrist who is located elsewhere, Gobel said.

“We wanted to meet their needs. One way to do this is this platform,” she said.

Besides talking to the patient, doctors can zoom in and take note of body language, eye contact and other signs they assess during an in-person visit, she said. “The doctor really has full control of how they see the patient … without that patient feeling like they’re being zoomed-in on.”

But while improved mental health care in the emergency room is a step forward, following up with patients afterward is the key to keeping them healthy, said Friedman of the American College of Emergency Physicians. The goal is to make sure patients are accessing the care they need once they leave the hospital, he said.

Yet sometimes that care is not available, or there are barriers, which is a problem that goes beyond the emergency room, Friedman said.

“Emergency physicians are very often the canaries in the coal mines. We see areas in the system that need help. And this is definitely an area that needs help,” he said.

At Advocate Illinois Masonic Medical Center in Lakeview, members of a behavioral health crisis team address patients’ mental health needs well beyond their visit to the hospital.

The Medically Integrated Crisis Community Support team is like “a little emergency room team out in the community,” said Stacey Brown, a social worker and coordinator of crisis triage. Team members include a psychiatrist, a nurse, a case manager, a chaplain and two social workers.

“We noticed a lot of patients come back (to the hospital),” Brown said. “Outpatient treatment would fail them, or they would fail it. Something wasn’t working.”

The team, created about five years ago, receives referrals from various parts of the hospital, or even from sources outside the hospital, for patients who need help and have a high hospital recidivism rate. The team will visit patients anywhere they are—at home, in a shelter, even a park if they’re homeless, Brown said.

Besides addressing mental health or other medical needs out in the field, team members will take patients to a doctor’s office, or assist in any nonmedical barrier to getting healthy, she said. That could include insurance or legal help, family reunification, finding a church or getting assistance with other community resources. For one patient, Brown said, a team member went with him to his bank to figure out why he couldn’t cash his checks.

“I think the thing that makes our team really special is we work hard to break down barriers to care,” she said. “And be really creative about how to solve problems.”

Since the hospital created the team, patients they have treated have had a 70% reduction in recidivism rates, Brown added.

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