February 2019–A mental health emergency center recently opened up in Nashville this month and is already at capacity sparking some questions about its designation and role in triage but more broadly about its value and need to expand. The Cooperative will see any patient but unlike traditional ERs the Cooperative currently only accepts Tennessee Medicaid insurance and even though there is no waitlist and average stays are 1-3 days, they don’t know when there will be room for more patients, according to Adam Graham, who is the program’s director of emergency services.
“It sounds like a same-day psychiatric facility to me,” says Tuann Luu, MD, an emergency doctor from California. By federal law, an emergency department cannot refuse care to anyone regardless of insurance. “It is not clear if they are turning away crisis situations.’
In its first weeks, police dropped off people to the new facilities rather than to hospital ERs. This was part of the goal and it has been working but Graham says they typically dropped of people with commercial insurance, not the Medicaid/more impoverished population the organization intended to serve. ‘We’ll treat anyone who walks in the door,’ Graham says. While they don’t bill commercial insurers, the Cooperative doesn’t bill a patient either, due to state grants that offset this cost.
‘We’re designed to be efficient in a suicide process,’ he says. That’s probably the largest goal and value over the typical situation of patients ending up in police departments or hospitals without any psych crisis-trained staff.
But it’s clear the Cooperative is itself facing a crisis in its first weeks as it tries to deal with massive demand without capacity. They were essentially full right away and then had 15 walk-ins. Plans for expansion are underway.
To help get ahead of a patient’s crisis the Cooperative has put out information in the community to encourage people without insurance to call their pre-screening triage line first. ‘If the person doesn’t have insurance we will refer them to a psych hospital to get admitted.’
Questions about its designation are reasonable given that the public may be unclear on the facility’s role other than its outside brand, ‘Mental Health Cooperative’. Graham is quick to say they don’t prefer the emergency room language because they don’t handle ‘medical’ emergencies.
‘We’re an alternative.’
An open floor concept is used with separate walk-in units for youth and adults as well as a large assessment unit. Patients won’t be in a room by themselves like a typical clinic or ER, but rather in a treatment setting where they can be monitored but also given immediate attention by nurses, doctors and specialists. Tennessee’s Department of Mental Health Services chipped in a $2.6 million grant for the project – the Cooperative added $900,000 and Nashville another $430,000, funding which has helped secure more staffing. And while its focus is on crisis intervention it provides non-crisis support such as medication management and therapy.
Once You’re In
Once a patient does get in, they enter into a group therapy engagement class and then are assigned a therapist who triages and treats the situation. The facility doesn’t look like a traditional ER. There are no bright lights and loud sounds. It’s set up to be more comforting to a person in a life or death psychiatric crisis situation.
‘I think the concept is a good one,” says Edward McGrath, director of support services at O’Connor Hospital in Albany New York. ‘Having not seen the environment, it sounds like one that would be conducive to helping patients in need.’ The Cooperative will help both adults and children. According to a new study, 1 in 7 children have a mental health condition that falls under the category of depression, anxiety, ADHD, bipolar disorder, or an eating disorder, all of which can lead to emergencies. A team of researchers from the University of Michigan studied 46.6 million children ages 5-8, and 7.7 million of them had at least one mental health condition. The national average of untreated mental health conditions among children is a little over 49 percent.
‘We’re in the trauma center and it is two doors down from the mental health center and it’s a lot of stimulation for them,’ says Christie Matthies, an ER doctor from Iowa. ‘Critical access ER is loud and bustling and it’s too much simulation. I think it would be a good idea and it would eliminate a lot of congestion. In Iowa it’s impossible to get a bed,’ Matthews laments. (See our related story, ‘If You Build It, Psych Field Gets Boost In Iowa’)
‘For me, the global issue is getting to the root cause of the problem,’ McGrath says. ‘What environment or stressors have we created for children to be in this situation. Children of years past seem to have managed well, on the surface at least, and life was very hard years ago. A great example I use is, even with no tolerance policies regarding bullying in schools, it’s worse now than years ago. Now social media is a player here, faceless people coming back at kids, such as telling a child to go ahead and kill themselves is very sad.’
Dealing with mental health emergencies is a new focus of payers too. Optum has been piloting a program out west to train EMS transport teams to divert psych crisis cases to special facilities just for these types of situations, and mental health ambulances have been popping up overseas. The London Ambulance Services NHS Trust is recruiting Mental Health Practitioners to increase their 24/7 specialist-enhanced clinical services on ambulances.
Louis Hochheiser, MD, a former chief medical leader for Humana, says he was skeptical of freestanding ERs back when they exploded on the scene around 2011 because they ‘were splitting emergencies’ and seemed to be focused more so on urgent care. But more than 69% of 212 medical directors we polled on this model today say there is high value given demand and ‘the uniqueness of treating a mental health crisis’ versus, for example, a heart attack or stroke. What several questioned however is less the triage and initial site of care but the discharge and transition, given so many patients falter or relapse after leaving these facilities without a proper plan of care or support system.
This new crisis center model has already made in-roads in diverting patients away from prisons and hospitals – so in the first month since opening they already addressing ‘system’ costs. What’s more, these centers can help address the burden on hospital ERs who lack in-house specialists and often have to scurry to find a psych consultant to drive to the hospital or call in. Telepsych services have taken off as a way to mitigate these challenges but if there were more of these mental health focused units, this could likely create a more efficient system. Fewer waits. Less chaos. Despite early challenges, there is clearly demand and at a minimum the makings of a blueprint for how to work with communities to address mental health crisis. How others may adapt these models in their communities or whether the healthcare investor community sees opportunity to help should be interesting. One obvious lesson from this is that there’s need from all populations – not just kids and adults, but those living in poverty and those with jobs or a more secure economic position. So how this Cooperative, and future ones like it, navigate patient access and insurance will be an important component to address.
-Erin O’Donnell and Bryan Cote