Hospitals help mental health patients – by sending them away
New diversion programs attempt to ease ER waits of hours or days
THE 11-YEAR-OLD GIRL was stuck in a hospital emergency room waiting for mental health services, after she found a sharp object in school and tried to hurt a teacher. The girl was struggling to reintegrate after the COVID pandemic and had been suffering from anxiety and depression.
Long waits for emergency psychiatric care at hospitals have become the norm in Massachusetts. But instead of forcing the young girl to wait until a treatment bed opened up, the hospital called Youth Villages, a nonprofit that provides home- and community-based mental health services.
After evaluations by the hospital and Youth Villages staff determined that the girl could be sent home safely, she was discharged home to her family, with intensive support from a Youth Village caseworker. Clinicians from Youth Village’s Marlborough office worked with her and her school, so school officials learned how to better communicate with the girl, while she learned how to better express her feelings.
Youth Villages began a pilot program in March, where they meet children in the emergency room, then bring them home with intensive supports. The agency has worked with 43 families in Southeastern and Central Massachusetts and recently expanded into Western Massachusetts. “There’s been so many times we’ve been able to respond in crisis to families, and they were like if you weren’t here, we would have ended up back in the emergency room,” said Meghan Hull, a clinical supervisor in the agency’s Marlborough office, which works with Leominster Hospital and Heywood Hospital in Gardner.
As a result, mental health providers have started searching for innovative ways to address it – in many cases, by diverting patients out of the emergency room into community-based settings, where they can get treatment more quickly and in a more appropriate, less expensive place. Diversion is not appropriate for every patient. Patients who pose a danger to themselves or others, have medical needs, or have severe mental illness, may need hospitalization. But experts say a large portion of individuals who arrive in the emergency room with mental health symptoms, like anxiety or depression, could be treated more effectively in an outpatient setting – if the services were available.
“What I hear constantly from people is we just need more beds,” said Jennifer LaRoche, vice president of acute and day programs for Clinical and Support Options, a Northampton agency that provides community mental health services. “For me, that’s just such a short-sighted response.”
Despite the efforts to develop alternative approaches such as the Youth Villages pilot initiative, most of the programs are small and new, and many families still lack access. “There’s a big gap in what’s being offered and what families actually know is there,” said Lisa Lambert, executive director of the Parent/Professional Advocacy League, which advocates for families of people with mental illness.
According to the Massachusetts Health Policy Commission, between January and September 2020, more than 28,000 behavioral health-related visits to the emergency department – 29 percent of all behavioral health ER visits – led to the patient waiting more than 12 hours for a bed. Among children, 39 percent of pediatric behavioral health patients who visited the emergency room between March and September boarded. On October 25, the Massachusetts Health and Hospital Association documented 639 patients waiting in emergency departments or medical-surgical units for a psychiatric bed, of whom 191 were younger than 18.
One issue is Massachusetts lost nearly 270 psychiatric beds in 2020, because of facility closures and because hospitals reduced capacity due to COVID protocols and staffing shortages. Hospitals and psychiatric facilities plan to add anothser 300 beds in 2021 and 2022.
But mental health practitioners say the need is not just for more beds, but for a system-wide approach that keeps people away from unnecessary inpatient treatment by providing better access to outpatient care. Danna Mauch, CEO of the Massachusetts Association for Mental Health, said emergency rooms are already under pressure. “To put people there who don’t belong there or need to be there is something that is not a good use of those limited resources and not useful to the people themselves,” Mauch said.
The children in the program generally are not receiving services elsewhere. Around 90 percent of cases her team has seen, Hull said, were pandemic-related: Children struggling with anxiety, depression, or suicidality because of isolation and loss of social supports due to COVID.
Of children who have been discharged from Youth Villages, 75 percent did not need a hospital placement and did not return to the ER.
“Our program is really about meeting children and families literally where they are in the emergency room and giving them an alternative path forward, to avoid the hospitalization altogether,” said Youth Villages executive director Matthew Stone.
Hospitals are also playing a role in diverting patients.
Jennifer Cox, director of behavioral health for Baystate Health, which operates Baystate Medical Center in Springfield, said the provider network is trying numerous initiatives to reduce long waits, although, she acknowledged, “We really haven’t seen the fruits of all of the experiments we’re trying yet.”
Through a partnership with Behavioral Health Network, a community-based provider, a social worker is stationed in the Baystate Medical Center emergency department to evaluate patients’ mental health needs. If someone does not need hospitalization, the social worker calls them a cab or a Behavioral Health Network staffer picks them up and takes them to one of the organization’s locations. Some patients go to the Living Room, a drop-in center where people can meet peers, get meals, and access services for a few hours. Others may go to a crisis stabilization center, which is like an inpatient unit for voluntary treatment.
“If you’re in psychiatric crisis but you’re medically stable and not needing restraint, you don’t need to be in an emergency room. Your needs are much better met in the community setting,” said Katherine Mague, senior vice president at Behavioral Health Network.
Cox estimates 20 to 30 adults have been diverted from Baystate Medical Center’s ER in the past month and a half. She does not have concrete data on diversions, primarily because the staff implementing the diversion programs have done it in addition to their regular jobs. “We’re building the airplane as we’re flying it,” Cox said.
Other hospitals are taking similar steps to reduce unnecessary emergency psychiatric admissions. In Northampton, Clinical and Support Options, a local mental health services agency, picks patients up from the Cooley Dickinson Hospital emergency room and takes them to one of the agency’s crisis centers or outpatient clinics for treatment. The agency also works with local doctors to encourage them to send mental health patients to community-based clinics. And Clinical and Support Options has started embedding clinicians with police departments to answer calls involving people with mental health needs, so individuals are connected to services rather than a hospital.
Two weeks ago, Boston Children’s Hospital launched a pilot with the Department of Mental Health and the Justice Resource Institute. Amara Azubuike, director of behavioral health policy for the hospital, said many children arriving in the emergency room were there because they could not access support elsewhere. Now, the hospital can call JRI, which provides intensive support to a child at home for four to eight weeks until they can get longer-term services. The program is funded by a federal grant and restricted to a handful of Boston area neighborhoods. Five children were referred the first two weeks.
Some of these initiatives were spurred by the state’s behavioral health roadmap, a document that lays out steps toward improving mental health treatment. It aims to provide increased access to mental health care in the community during non-business hours and at new locations, like urgent care centers or homes through mobile teams.
Mass General Brigham and the Blue Cross Blue Shield Foundation also recently announced grant programs to expand behavioral health urgent care.
There may be more resources available soon through the federal American Rescue Plan Act. Both the Massachusetts House and Senate are proposing spending hundreds of millions of dollars on behavioral health care.Mauch, the Massachusetts Association for Mental Health CEO, said some mental health agencies were already working on these initiatives pre-pandemic. For example, an agency in Martha’s Vineyard, in partnership with a local school, created a suite of rooms where a child in crisis can wait comfortably while a clinician on call is summoned. But the pandemic accelerated interest in emergency room diversion.
“Being in the emergency department during COVID was a huge risk, and some people stayed away and got worse, and others started thinking about, okay, what can we do?” Mauch said. “These models that exist, why aren’t we doing more with them?”