Evidence Based Practice: Decreasing Psychiatric Revisits to the Emergency Department

Inpatient psychiatric settings anticipate changes in reimbursement that will link payment rates to objective quality measures. Readmission rates are expected to be one of the quality measures. Inpatient areas are undertaking initiatives to decrease readmission rates in preparation for this change. The emphasis on avoiding readmission could cause an increase in emergency room revisit rates by psychiatric patients. In preparation for this potential impact, the mental health emergency service within the Emergency Department of a not-for-profit community based hospital implemented a proactive process improvement plan. The plan's goal was to insure that all patients’ care was provided according to a defined standardize best practice process. Steps of the plan focused on (1) improving treatment providers’ communications across the continuum of care, (2) enhancing communication between the mental health emergency department nurses and the on-call psychiatrists, (3) developing on-line decisional support to enhance communication, and (4) providing providers with feedback on the impact of changes. Implementation of the improvement process decreased the mean psychiatric emergency revisit rate from 5.7% to 4.3% and decreased the variability in monthly rates from a range of 1.83%–9.53% to a range of 3.53%–5.56%.     

Implementation of the Victorian Emergency Department Mental Health Triage Tool

In 2005, the Department of Human Services (Victoria) commissioned the National Institute of Clinical Studies (NICS) to develop and implement a statewide emergency department triage tool to improve the ED triage processes for mental health presentations to Victorian Emergency Departments. The project was undertaken over a 7-month period from September 2005 to March 2006. This paper describes the implementation approach undertaken by NICS and the outcomes of the project.     

Evaluating an Alternative to the Emergency Department for Adults in Mental Health Crisis

Adults with mental health issues lack clinically indicated options when in crisis. Historically, the emergency department (ED) has been the primary source of intervention largely due to funding cuts and decreased community resources in the USA. The literature highlights drastic mental health funding cuts alongside an increased prevalence of mental illness. A community-based alternative for adults in mental health crises was subsequently developed as a model of crisis care. The program has demonstrated impressive short-term outcomes, typically avoiding ED admissions in over 95% of the clients. This number benefits both the consumers who otherwise rely on the ED and the State of Illinois in terms of cost savings for avoidable ED visits. The current deflection rate only reflects ED admissions deflected on the day of the visit to the crisis respite program. To establish the long-term outcomes for this model, follow-up phone calls were conducted to determine whether or not the individual required an ED visit for a psychiatric reason within 30 days of utilization of the program. The follow-up phone calls began in May and continued for eight weeks. At this time, the data collected were analyzed and the outcomes of the program were further evaluated. Based on the follow-up survey results, the positive long-term outcomes validate this model as a cost-saving and clinically indicated alternative to the ED. Establishing such outcomes was necessary to ensure continued funding and to support establishment of similar models of crisis care.     

Mental Health–related Emergency Department Visits Associated With Cannabis in Colorado

Background

Cannabis legalization in Colorado resulted in increased cannabis‐associated health care utilization. Our objective was to examine cooccurrence of cannabis and mental health diagnostic coding in Colorado emergency department (ED) discharges and replicate the study in a subpopulation of ED visits where cannabis involvement and psychiatric diagnosis were confirmed through medical review.

Methods

We collected statewide ED International Classification of Diseases, 9th Revision, Clinical Modification diagnoses from the Colorado Hospital Association and a subpopulation of ED visits from a large, academic hospital from 2012 to 2014. Diagnosis codes identified visits associated with mental health and cannabis. Codes for mental health conditions and cannabis were confirmed by manual records review in the academic hospital subpopulation. Prevalence ratios (PRs) of mental health ED discharges were calculated to compare cannabis‐associated visits to those without cannabis. Rates of mental health and cannabis‐associated ED discharges were examined over time.

Results

Statewide data demonstrated a fivefold higher prevalence of mental health diagnoses in cannabis‐associated ED visits (PR = 5.35, 95% confidence interval [CI], 5.27–5.43) compared to visits without cannabis. The hospital subpopulation supported this finding with a fourfold higher prevalence of psychiatric complaints in cannabis attributable ED visits (PR = 4.87, 95% CI = 4.36–5.44) compared to visits not attributable to cannabis. Statewide rates of ED visits associated with both cannabis and mental health significantly increased from 2012 to 2014 from 224.5 to 268.4 per 100,000 (p < 0.0001).

Conclusions

In Colorado, the prevalence of mental health conditions in ED visits with cannabis‐associated diagnostic codes is higher than in those without cannabis. There is a need for further research determining if these findings are truly attributed to cannabis or merely coincident with concurrent increased use and availability.

     

Effecting Successful Community Re-Entry: Systems of Care Community Based Mental Health Services

ABSTRACT

The need for system reform for child and adolescent mental health services, long recognized as a vital issue, continues to challenge mental health professionals. While past legislation has not adequately addressed the issues, the 2003 President's New Freedom Commission may begin to reorient mental health systems toward recovery. Supported by this legislation, the “systems of care” movement promotes interagency mental health delivery systems with a family focus. Occupational therapists, though perhaps often overlooked as treatment teams are developed, can be valuable interdisciplinary team members in systems of care programs. Increased communication and collaboration are needed to achieve a coordinated, collaborative interdisciplinary approach. This is particularly critical to effect successful community reintegration of children and adolescents who are returning from residential treatment.     

Emergency Department Initiatives to Improve the Public Health

Each year, the Society for Academic Emergency Medicine, the American College of Emergency Physicians, and the American Board of Emergency Medicine co-sponsor an educational session at the Association of American Medical Colleges Annual Meeting. The 1997 session was entitled “Emergency Department Initiatives to Improve the Public Health,” and included presentations by 4 invited speakers: Dr. Lewis Goldfrank, Director of Emergency Medicine at Bellevue Hospital Center and New York University Medical Center; Dr. Dennis Andrulis, Director of the Office of Urban Populations at the New York Academy of Medicine; Dr. Robert D'Alessandri, Vice President for Health Sciences and Dean of the School of Medicine at West Virginia University; and Dr. Arthur Kellermann, Acting Chief of Emergency Medicine at Emory University. Each speaker focused on a particular aspect of emergency medicine and the health of the public. The following article summarizes some of the session's ideas and themes.     

The Delivery of Mental Health Services to Children

JCPN Commentary presents a series of observations, opinions, and analyses of issues and trends in education and practice in psychiatric and mental health nursing, and social policy factors that influence families, or the delivery of health services to youth and their families.