By Robyn Baek
For hospitals around the country, there is a growing, systemic trend towards the number of behavioral health patients arriving at the emergency department outpacing the resources in place to support them.
Hospital emergency departments are not built for mental health. As a result, when patients arrive at an ED with symptoms of mental health concern, and the courses of treatment available within the department are often limited. Patients can receive needed drugs, oversight and an initial psychological assessment, but little else without seeking specialized care. EDs are built to move patients quickly into inpatient or outpatient environments where they can receive ongoing psychiatric support.
However, many EDs are understaffed to handle the volume of psychiatric patients visiting, and thus struggle to make a timely qualified assessment, which can lead to strained resources, extended wait times and expensive boarding costs.
In the case of behavioral and psychiatric cases in the ED, the reasons for the growing problem are well established. An ever-expanding need for psychiatric specialists, a lack of accessibility to existing specialists and a multitude of societal and socioeconomic issues mean fewer psychiatric resources in the ED, at a time when the number of patients in need continues to grow. Here’s the breakdown:
One in eight patients visiting the ED have a mental health or substance abuse issue. When those patients arrive, they wait longer because the hospitals often lack psychiatric resources to process their needs; on average, mental health patients wait three times as long as non-psychiatric patients. Those wait times cost money. The average boarding time for a psychiatric patient ranges between 8 and 34 hours, with an average cost of $2,264. Moreover, that money might never be realized by the organization. Reimbursement for mental health is among the lowest in health care, with more than 75 percent of respondents to one national survey reporting net losses that continue to worsen from a three-year average of $481,000 in 2013 to more than $550,000 in 2017.
Then there are the associated costs. Many hospitals create a separate area within the emergency department for mental health patients with additional costs for security personnel. Many also hire locum tenens psychiatrists at premium rates. They partner with law enforcement, with social services and with placement facilities. In each of these examples, financial resources are today being applied to mental health in the ED because of overflowing and understaffed departments that could be spent in other ways, if there was a better solution in place.
The problem isn’t going to improve either, at least not soon. Demand for psychiatrists will be 25% higher than supply by 2025. More than half (55%) of states have severe shortages in child and adolescent psychiatry. The future seems likely to include more mental health cases and fewer resources to serve them.
As the gap between mental health needs and resources continues to widen, hospitals can also expect an increase in violence. 75% of emergency department doctors experience at least one violent incident annually, and 25% of nurses experience physical violence more than 20 times during a three-year period.
All of these factors together result in quantifiable and likely rising costs for mental health in the ED. Though it will never be the ideal place to keep mental health patients, one solution proving itself today is telePsychiatry.
Imagine a hospital with 45,000 ED visits per year, with 2 or 3 child or adolescent patients per day presenting with behavioral health issues. Like many others, this particular hospital lacks a general psychiatrist on staff willing or able to treat patients under 18. Neither the emergency department nor the social work staff (typically an MSW) are fully capable of assessing and treating underage psychiatric patients. It’s vital that these cases be admitted to inpatient units or dispatched with outpatient instructions quickly. However, the hospital is not staffed to handle this specific situation. So, the patient waits, often for days, until the appropriate personnel makes a qualified opinion.
Think of the cost. The stress. The strain on hospital resources and staff. Much is left to be desired in cases like these, for everyone involved.
The emergent field of telemedicine can help this hospital. A telePsychiatry program provides psychiatric expertise to within minutes, on demand. The psychiatrist makes an evaluation while working remotely via in-room technology, and the patient is then discharged with outpatient instructions, or placed into an inpatient community. The entire process then takes the patient a few hours to navigate, not days, and saves hundreds of thousands of dollars for a hospital each year in boarding costs. Specialists are on-call, all the time.
What’s more: when these patients are treated by a psychiatrist while boarding, many behavioral issues stabilize, and their outcome changes. The strain on the system, the patients and doctors, on parents and caregivers and providers is unilaterally reduced, and beds open up for other urgent cases.
Though the psychiatric problems facing EDs are daunting at first blush, a telePsychiatry solution is practical and straightforward. There are too many psychiatric patients and not enough psychiatrists in emergency departments around the country. However, by connecting a telePsychiatrist to a patient who might otherwise wait for hours or days for treatment, the ED overflow is slowed, the patient is sent to receive more specialized care and the hospital returns to a more efficient state.
If more hospitals chose to engage in telemedicine programs, and if more emergency departments looked to telePsychiatry as a solution to their mental health burdens, patients would experience improved outcomes and the EDs in countless hospitals would run more efficiently and effectively.
Robyn Baek is Vice President, Analytics for SOC Telemed.