Behavioral Health Crisis Care: Moving Towards Less Dependence on the Emergency Department

Behavioral health care in the United States underwent a significant transformation in the latter half of the 20th century with a mass movement towards deinstitutionalization. Since then, we have seen community mental health services struggle to adequately care for the growing number of individuals with serious mental illness and substance abuse. As a result, emergency departments have shouldered a large proportion of the increased need for behavioral health services. In many communities, the ED may be the only place that an individual in crisis can go to for psychiatric evaluation at all hours of the day. With the recent passage of health reform and a focus on studying innovative care models, new behavioral health facilities that provide an array of services have begun to emerge. These novel facilities aim to be an alternative to the emergency room for individuals in mental health or substance abuse crisis. The purpose of this Master's Paper is to explore the setting of psychiatric emergency care and its relationship to the emergency department, as well as report on the experience of a novel psychiatric crisis and assessment facility in Wake County, North Carolina. The first part of this paper is a systematic review of the literature on interventions or strategies for reducing patient transfers from psychiatric crisis centers to the ED, experiences with ED transfers in other settings, and the process of "medical clearance" of psychiatric patients in emergency settings. The review demonstrated that there is a significant gap in the literature pertaining to patient transfers from psychiatric crisis centers to the ED. In addition, a majority of the reviewed studies on "medical clearance" of psychiatric patients suggested that routine laboratory testing is unnecessary and may be overused. Furthermore, they acknowledged the need for more prospective studies of medical clearance protocols for this patient population. Following the systematic literature review, this paper continues with an original manuscript that presents the results of a descriptive study of individuals who presented to the Wakebrook Crisis and Assessment facility and were subsequently transferred to a medical ED. The results of this study demonstrated an overall downward trend in ED transfer rate since the initiation of a co-located primary care team but also identified a subpopulation of potentially avoidable transfers that occurred. This study is unique in that it describes a population of individuals who presented to a psychiatric crisis center but were later seen in a medical ED for either medical or psychiatric reasons. While it is a preliminary descriptive analysis, it provides a path for future research into the effectiveness of these novel facilities in preventing unnecessary ED visits and improving patient outcomes.Master of Public Healt