Reducing Frequent Utilization of Psychiatric Emergency Services Among Veterans While Maintaining Quality of Care
Abstract
Objective:
Use of psychiatric emergency services in emergency departments (EDs) and inpatient psychiatry units contributes substantially to the cost of mental health care. Among patients who utilize psychiatric emergency services, a small percentage (“high utilizers”) contributes a disproportionate share of the total cost, yet little is known about the context of care for these patients. This study employed qualitative methods to identify barriers to and facilitators of reducing use of psychiatric emergency services among high utilizers.
Methods:
Semistructured phone interviews were conducted with 31 directors of mental health services and providers of psychiatric emergency services across 22 Veterans Health Administration medical centers. The Consolidated Framework for Implementation Research was used to guide the interviews to evaluate the context of care for high utilizers. Thematic coding was used to identify barriers to and facilitators of reducing utilization.
Results:
Barriers emerged at the patient level (for example, treatment nonadherence and transiency), provider level (for example, stigma toward high utilizers and lack of expertise and training in the management of psychiatric issues among ED staff), and system level (for example, lack of specialized services to address short- and long-term care needs). Facilitators included recovery-oriented care; interdisciplinary care coordination and case management, with emphasis on the role of psychiatric social workers; and predictive analytics to flag high utilizers.
Conclusions:
The findings lay the groundwork for the design of novel approaches to care for high utilizers of psychiatric emergency services while limiting provider burnout, managing costs, and optimizing treatment outcomes.
Use of psychiatric emergency services, usually in emergency departments (EDs) or inpatient psychiatry units, contributes substantially to health care costs in the United States (1,2). That is particularly true of the Veterans Health Administration (VHA), a safety-net provider serving a population with high rates of psychiatric problems (3). Over the past decade, there has been an increase in use of VHA mental health services (3–5), with utilization of psychiatric emergency services contributing approximately one-third of the total cost of care for VHA psychiatric patients (6). Across VHA and non-VHA hospitals, 5% to 10% of patients who utilize psychiatric emergency services contribute a disproportionate share of the cost of these services (7–13).
To date, research on high utilizers of psychiatric emergency services has relied on administrative data to identify these patients’ characteristics (13,14). Extant research in this area has linked frequent utilization of psychiatric emergency services to diagnoses of serious mental illness, substance use disorder, and personality disorder as well as to homelessness and detoxification service utilization (11–17). However, administrative data lack information on context of care, such as available resources and care delivery processes, which may affect the frequency of service utilization (18–20). Also, there is an absence of research on the context of care as it relates to psychiatric emergency services in the VHA (16), even though the VHA is the largest provider of public mental health care in the United States.
Qualitative methods are well suited to understand the context of care for high utilizers of psychiatric emergency services. Such an inquiry can identify barriers to and facilitators of reducing these patients’ use of these services (21). To our knowledge, no such study has been conducted to date. Investigating these issues within an integrated, near-universal health care system such as the VHA can yield valuable insights for ongoing debates about health care in the United States, specifically about access to and cost of health care for the most vulnerable patients.
We examined perceptions of stakeholders across VHA regarding the context of care for high utilizers of psychiatric emergency services to identify barriers to and facilitators of reducing use of these high-cost services. We interviewed a national sample of directors of mental health services and providers of psychiatric emergency services. Including directors of mental health services had the advantage of obtaining system-level perspectives on this topic and on the continuum of psychiatric care available to patients.
Methods
Study Design
Directors of mental health services and providers of psychiatric emergency services participated in a semistructured telephone interview. To obtain feedback from informants across a range of facilities, we calculated the ratio of high utilizers of psychiatric emergency services to total number of unique patients who received psychiatric emergency services in fiscal years 2011 and 2012 for each VHA facility that provides these services in an ED or an acute inpatient psychiatry unit (N=128). An encounter involving psychiatric emergency services was defined as an ED visit (stop code 130) or a unique acute inpatient psychiatry admission (bed section code 93) with a corresponding ICD-9 psychiatric diagnosis. We included inpatient admissions so the findings would generalize to the full continuum of emergency care for patients.
A high utilizer was defined as an individual with three or more encounters involving psychiatric emergency services during the study period, a definition consistent with the literature (11). Data on ED visits and inpatient psychiatric admissions (and corresponding diagnoses) were obtained from VHA’s National Patient Care Database and Patient Treatment Files, respectively. In the literature, psychiatric emergency services typically refer to dedicated units for psychiatric emergencies (18). We defined the term broadly in order to capture inpatient psychiatry admissions. However, the focus of the study was largely psychiatric emergency services in EDs. Most encounters (96.5%) in our data were based on an ED visit; only 3.5% of encounters were unique admissions to an inpatient psychiatry unit that were not preceded by an ED visit.
Across facilities, the ratio of high utilizers to total number of unique patients who received psychiatric emergency services in FY 2011–2012 ranged from 5.7% to 21.1% (mean±SD=12.8%±4.3%). Thus, on average, one of every eight patients who received psychiatric emergency services at a VHA facility was a high utilizer. To maximize variation and identify themes that cut across the distribution, we used a multistep process to identify facilities for conducting interviews. First, stratified purposeful sampling was used to identify facilities in which the percentage of high utilizers fell within the upper (≥14.6%) or lower (≤10.2%) quartile (22). Next, two facilities from each of five VHA complexity levels (1a, 1b, 1c, 2, and 3) were randomly selected from both quartiles (23). Highest-complexity facilities (level 1a) are marked by high volume, higher-risk patients, and specialized clinical services. Lowest-complexity facilities (level 3) are marked by low volume, lower-risk patients, and few or no specialized clinical services. When facilities were not eligible because they reported not having emergency services (N=2), they did not respond to e-mail requests (N=11), or all points of contact declined participation (N=6), another facility was randomly selected from the corresponding quartile. Forty-one facilities, 21 from the lower quartile and 20 from the upper quartile, were randomly selected and contacted.
For each of the selected facilities, we used online databases to identify the names and e-mail addresses of directors of mental health services (22). Directors were contacted via e-mail with a letter of invitation to participate. Phone interviews were conducted by the second author and lasted 45 minutes, on average. Participants were not made aware of their facilities’ ratio of high utilizers to total number of unique psychiatric patients treated in FY 2011–2012. After the interview, participants were asked to provide the name and contact information for another administrator or provider of psychiatric emergency services at their facility. Referrals were contacted via e-mail and invited to participate. Interviews continued until at least one informant from each of the five facility complexity levels was enrolled and thematic saturation was reached (24). Interviews were conducted from January to June 2015. All procedures were approved by the local institutional review board. All participants provided informed consent.
Qualitative Interview Guide
The interview guide was informed by the Consolidated Framework for Implementation Research (CFIR) (25), which consolidates constructs from implementation science frameworks to understand factors that may affect quality of care for a population in a particular setting. Participants were queried on CFIR domains related to the context of care for high utilizers of psychiatric emergency services (see box on the next page) (18–20).
QUESTIONS FROM THE INTERVIEW GUIDE USED TO IDENTIFY BARRIERS TO AND FACILITATORS OF REDUCING PSYCHIATRIC EMERGENCY SERVICE UTILIZATION AMONG VETERAN PSYCHIATRIC PATIENTS
Background
Can you tell me a little bit about your role at the VHA?
How long have you worked in this role?
Please describe how patients flow through your service (the process of admitting, triaging, transferring, and discharging veterans with mental health complaints)?
What is your experience in working with high utilizers of psychiatric emergency services?
Some VHA facilities have higher and lower rates in terms of the proportion of psychiatric patients who repeatedly use psychiatric emergency services. Why do you think some have higher rates, and why do you think some have lower rates?
Characteristics of high utilizers
Please give me an example of a high utilizer of psychiatric emergency services.
How do high utilizers tend to access these services?
How is caring for a high utilizer different than other veterans you treat?
What works well in treating high utilizers?
What are some challenges to treating high utilizers?
Networks and communication
How does your service coordinate care for high utilizers?
In terms of discharge and continuing care planning, what works well in transitioning high utilizers to other programs or services?
What are the challenges in transitioning high utilizers to other programs or services?
Structural characteristics and available resources
What structural factors, such as organization of the team, division of labor, and available resources, facilitate your ability to provide care to high utilizers?
What structural factors are barriers to providing care to high utilizers?
What additional knowledge, resources, or services would help you provide better care to high utilizers in order to reduce their risk of repeated hospitalizations?
Policies
What are some policies at your facility that have facilitated reducing repeated use of psychiatric emergency services?
What policy changes would help to reduce frequent utilization of psychiatric emergency services?
a Headings correspond to context-of-care domains from the Consolidated Framework for Implementation Research (25). For interviewees, a high utilizer was defined as a patient with mental health issues who is frequently treated in an emergency department or acute inpatient psychiatry unit.
Data Analysis
We employed a modified version of Rapid Identification of Themes From Audio-Recordings (26). After each interview, the second author took detailed notes by using a template to summarize responses to questions and document preliminary themes reported by participants related to barriers to and facilitators of reducing utilization of psychiatric emergency services. Six codes were specified a priori (patient-, provider-, and systems-level barriers and patient-, provider-, and systems-level facilitators) (27). These codes and preliminary themes were operationalized in a codebook developed by two authors (DB and LM). The postinterview notes for participants from facilities in the upper and lower quartiles were independently reviewed by DB and LM. The preliminary themes that were documented were the same for facilities in the upper and lower quartiles; thus, the data were analyzed together. Once interview notes were completed, we copied the notes into an Excel matrix to compare the preliminary themes within each code (columns) and across participants (rows). The matrix was organized into the aforementioned codes, and a summary of participants’ responses related to the code was used in each cell. Next, the same two authors independently reviewed the matrix to apply the final themes to each cell and identified direct quotes related to each theme by referring to the full transcripts of the interviews. We then compared their application of themes to the matrix and engaged in a consensus process to rectify disagreements.
Results
Participants were 31 key informants across 22 VHA facilities, 12 in the lower quartile and 10 in the upper quartile, with the following facility complexity levels: 1a (N=7), 1b (N=3), 1c (N=3), 2 (N=4), and 3 (N=5). Thirteen participants were directors of mental health services (all mental health services [N=7], EDs [N=4], and outpatient services [N=2]), and 18 were providers of psychiatric emergency services (general EDs [N=11], psychiatric EDs [N=4], and inpatient psychiatric units [N=3]). Across all participants, 13 were psychiatrists, 12 were social workers, four were psychologists, and two were nurse practitioners. Participants were mostly female (N=16) and non-Hispanic Caucasian (N=25), with a mean age of 49.5±8.6. Participants had been in their current role for 6.9±5.8 years.
Barriers to Reducing Utilization of Psychiatric Emergency Services
Patient nonadherence to treatment recommendations.
Participants described patient nonadherence to treatment recommendations—for example, not attending outpatient appointments and medication noncompliance—as a barrier to reducing utilization of psychiatric emergency services (Table 1). Participants highlighted several factors that contributed in their view to nonadherence to outpatient care by high utilizers, including patients’ distrust of non-ED providers, lack of patient support networks to facilitate care engagement, and geographic barriers and lack of transportation.
| Barrier (theme and subthemes) | N | Sample quotations |
|---|---|---|
| Patient nonadherence to treatment recommendations | 16 | |
| Not attending appointments with outpatient services or not complying with medication regimens | “…the ones that keep coming back . . . the compliance is not there, even though we probably provided whatever we can. . . . We have everything here. We have all this to offer, but of course if they don’t comply we’re back to square one.” (P3; psychiatrist, general ED) | |
| Distrust of non-ED providers | “In speaking to some of these veterans, a lot of them said, ‘We go to the ED because we don't trust our primary care doctor or the team. We know that we can get seen and treated at the ED.’ And so what we identified was there was this lack of relationship [with non-ED providers].” (P1; psychologist, director of primary care–mental health services) | |
| Lack of a support network to facilitate care engagement | “The ones who we see utilizing a lot tend to really have no one and nothing and don’t know how to function on their own. . . . A lot of times what I would notice on the inpatient acute unit is when they’re in that unit and they have structure and they’re around people who care and they can engage with, they do really well, and then they’re discharged . . . and then they just don’t do well because there isn’t that structure and then they’re back here again.” (P4; social worker, general ED) “Part of the illness that's driving the [high utilization] is they don't have a strong enough support system to follow through with treatment outside of that ER visit.” (P25; psychologist, associate chief of staff, mental health services) | |
| Geographic and transportation barriers to attending outpatient care | “People who have had . . . several admissions or multiple admissions, and they don't seem to be good at making the transition to outpatient care. . . . Sometimes it’s distance or they'll say they don't have money for transportation.” (P7; psychiatrist, general ED) “We did do a survey of these guys downstairs to find out what kept them from following up with us, and the majority of them said transportation.” (P11; psychiatrist, associate chief of staff, mental health services) | |
| Patient transiency | 10 | |
| No reliable contact information or stable residence, which hinders efforts to track and follow up patients in order to link them to services | “Most of the time these guys get out and leave the ED, they’re off the grid and we can't find them. They're very difficult to find. So that's the hardest part.” (P11; psychiatrist, associate chief of staff, mental health services) “Another thing is the transients. Some people we have, they’re here for a month, two months, they come to the ER three or four times and then we don’t see them anymore. They’re transitioning through south Florida, they’re heading out to the Keys or they’re heading out somewhere else and then of course you lose them.” (P3; psychiatrist, general ED) “[The problem is] inaccurate phone numbers and inaccurate addresses because they're transient; they move a lot. And if they no-show an appointment, you try to call them and the number's dead. Or you leave a message and never get a call back, or the voice mail's not set up . . . and so it's sometimes really hard to track these patients and find them and give them a phone call or send them a letter in the mail or something like that . . . and the next time you see them is in the ED.” (P27; supervisory social worker, mental health services) | |
| Staff stigma toward high utilizers | 11 | |
| Demoralization when treating high utilizers, which negatively affects the quality of care that these patients receive | ||
| Challenges to developing a therapeutic relationship | “[High utilizers] come to the ED and staff are immediately turned off. There's, I think, less caring from the medical staff. [High utilizers] are seen as a bother, they're seen as inconvenience for them and a patient's going to read that immediately.” (P25; psychologist, associate chief of staff, mental health services) “The number one thing I have with high utilization people in the ED is my own prejudice. I don't always successfully overcome it. It's like, ‘Oh, no, not again. Oh yeah, I read my last three notes. I know this guy inside and out.’ The danger in that is you are going to miss the subtle change—the boy who cries wolf.” (P29; social worker, general ED) | |
| Challenges of managing parasuicidality and inappropriate use of these services among patients with personality disorders | “They can sometimes make you feel manipulated. I think one of the hardest things in working with people with personality disorders is the worry about their dangerousness, to themselves usually.” (P17; psychiatrist, inpatient unit) “Sometimes they want to come in and get the “benzos” and then recant that they're having suicidal ideation because they've got what they want and they want to leave. And so trying to manage that and working with the staff in the ED to educate. I know that they get overwhelmed with these frequent fliers.” (P26; social worker, general ED) | |
| Lack of training and expertise among ED staff in the management of psychiatric issues | 11 | |
| Limited ability to identify community resources for patients and to develop appropriate discharge plans | “The social workers will sort of throw up their hands and say, “I'm a medical social worker. I don't know how to find rehab programs. I don't know what this is.” (P17; psychiatrist, inpatient unit) “We have a culture in our emergency room that the nursing staff, they're…uncomfortable with having psychiatric emergencies… there are a number of factors with the nursing care in the emergency room that makes it challenging to manage these high utilizers.” (P17; psychiatrist, inpatient unit) “The biggest single barrier to getting people seen, quite frankly, is the whole middle of the night thing when we're relying on psychiatric residents who vary . . . in terms of their motivation and confidence to get the patients hooked in and get a decent treatment plan.” (P19; psychiatrist, general ED) | |
| Lack of specialized services to address short- and long-term care needs | 13 | |
| Community social services and partnerships | “We’re going to have to create more liaisons with community resources, community organizations . . . where I think it really needs to happen and would be very helpful would be in terms of aftercare mental health . . . transitional or supportive housing.” (P4; social worker, general ED) | |
| Long-term care for patients with serious mental illness, chronic substance use disorders, or dementia | “Part of it is our lack of funding for long-term structured programs where patients can actually get long-term care. And someone who's been drinking for 20 years who comes into a psych ED all the time, sending them to a 21-day outpatient program is just often not enough, but that's all we have. . . . So, not having access to larger, more structured programs is a barrier.” (P13; psychiatrist, director of psychiatric ED) | |
| Pharmacotherapy for patients with alcohol and opiate use disorders | “Our substance use disorder program is very behind the times in terms of the treatments for addiction. Until I came, they weren't using naltrexone. That's standard care for alcoholism.” (P32; psychiatrist, general ED) “I'm thinking of a kind of core of people who have recurrent problems with heroin use. This is really a big problem that I've been seeing, that many veterans, you know, don't want to take methadone long term. . . . They all want suboxone. We do have a suboxone program, but our program has somewhat stringent requirements for that.” (P7; psychiatrist, general ED) | |
| Outpatient alcohol and opiate detoxification services | “I think the only one I would like to address somehow with this one area is to come up with some better strategies for detox, both alcohol and opioid detox. They're just tricky areas of when you need inpatient versus when it can be done outpatient. At this point, we really don't have any real options for outpatient alcohol or opioid detox.” (P10; social worker, general ED) |
a
For interviewees, a high utilizer was defined as a patient with mental health issues who is frequently treated in an emergency department or acute inpatient psychiatry unit. P, participant; ED, emergency department; VHA, Veterans Health Administration
Patient transiency.
Participants highlighted the transiency of high utilizers as another barrier to reducing frequent utilization of psychiatric emergency services. For example, high utilizers often have no reliable contact information or stable residence. Participants distinguished this factor from patient nonadherence in that it was seen as hindering the ability of staff, including providers of services other than psychiatric emergency care, to track and follow up with patients to link them to services.
Staff stigma toward high utilizers.
A provider-level barrier to reducing frequent utilization of psychiatric emergency services was stigma among staff toward high utilizers, which impedes their ability to develop a therapeutic relationship with patients and negatively affects the quality of care received. Relatedly, participants reported that some high utilizers, particularly those with personality disorders, often exhibit parasuicidality and engage in inappropriate use of psychiatric emergency services and that staff who provide these services do not know how to manage these situations.
Lack of training and expertise in the management of psychiatric issues.
Another provider-level barrier was lack of training among ED staff at nonpsychiatric facilities (for example, medical social workers and nurses) in how to identify community resources for high utilizers and how to develop appropriate discharge plans for patients with psychiatric disorders.
Lack of specialized services to address short- and long-term care needs.
Across facility complexity levels, participants reported that a lack of several specialized services contributed to frequent utilization of psychiatric emergency services. These services included community (non-VHA) social services and partnerships; long-term care for those with serious mental illness, chronic substance abuse, or dementia; pharmacotherapy for patients with alcohol and opiate use disorders; and outpatient alcohol and opiate detoxification services.
Facilitators of Reducing Utilization of Psychiatric Emergency Services
Recovery-oriented care.
Participants described the value of relationship building in reducing utilization of psychiatric emergency services, particularly specific patient-centered practices that are helpful in the relationship-building process (Table 2). Motivational interviewing, connecting patients to peer-based services, and engaging family members in care planning were identified as important in relationship building. These practices are all elements of recovery-oriented care (28).
| Facilitator (theme and subthemes) | N | Sample quotations |
|---|---|---|
| Recovery-oriented care | 16 | |
| Importance of building relationships with patients | “I would say our successes come from staff who are willing to really engage the veterans. . . . Building a relationship can reduce utilization. When you build relationships and get to know your veterans, they're more likely to listen to you.” (P1; psychologist, director of primary care–mental health services) | |
| Motivational interviewing to facilitate patients’ engagement in substance use disorder treatment | “Sometimes, they're not going to be seeing it on their own, or they might come in and say, ‘Oh, I'm tired of living this way and just don't want to do [it] anymore. I need to stop drinking.’ It's important for us to intervene with treatment options and therapeutic interventions, just like motivational interviewing.” (P16; social worker, inpatient unit) | |
| Peer groups and peer-based services to enhance patients’ support networks and facilitate engagement in outpatient care | “We have a psychiatric rehabilitation program. . . . They have also peer support specialists and the whole team of people, and they have different kinds of groups and so on, and activities to try to engage them in an outpatient type treatment. We have had some success with some of those people.” (P7; psychiatrist, general ED) | |
| Engaging family members in patients’ discharge planning | “[We work on] bringing in the family and encouraging them to participate in this discharge plan so that we try to treat the whole patient, not just the fact that they need to go home.” (P18; social worker, director of outpatient mental health services) | |
| Increased opportunities for education, training, and supervision of ED staff in management of psychiatric patients | 9 | |
| Potential benefit of mitigating provider stigma of high utilizers | “[To better manage high utilizers], we need to have strong clinical supervision for [ED] providers. We need to be addressing staff burnout . . . so that the providers could then go back and feel refreshed to implement the skills they already had.” (P28; social worker, general ED). “A lot of what my team does as well is often trying to educate the ED staff, about various diagnoses and to minimize stigma. Often there's a big piece with substance abuse and the perception that it's their choice . . . the nurses and the health techs [in the ED] that are doing the one-to-one evaluations will often just get frustrated about the same old story again and again and again.” (P10; social worker, general ED) “I think our staff could use more evidence-based training of skills—skill set, evidence-based theory process. I don't think that our nurses are as trained in evidence-based theories as . . . they could [be].” (P16; social worker, inpatient unit) | |
| Interdisciplinary, team-based care | 14 | |
| Better communication and care coordination for high utilizers within and across services to help reduce unnecessary ED visits | “[What’s needed is] a really good sort of interdisciplinary team and working really well together in sort of meeting daily to sort of make the progress of the veteran, move it along. So everybody sort of brings their own resources to that. I think [that] works really well.” (P4; social worker, general ED) “Our mental health clinic has been more clearly organized into teams where the teams have representation by a psychiatrist, psychologist, nurses, and social work staff. . . . I think that the team approach has helped us. If a patient's psychiatrist is not available, we can reach out to somebody else on the team and help provide some continuity to keep [the patient] out of the ED between visits.” (P7; psychiatrist, general ED) | |
| Limiting high utilizers’ potential to “split” their care providers to mitigate provider burnout | “I think the piece of needing to have more collaboration outside of the service that I am in is really kind of mandatory for it to be effective . . . so that [I] have other providers that I'm connected to that I can share my frustrations with and that I feel supported by. That I'm now working with a team with this difficult patient instead of working by myself with this difficult patient.” (P28; social worker, general ED) “After an ED social worker organized a team meeting with the care providers of a high utilizer, the patient was told, ‘It doesn't matter if you walk into the substance use clinic . . . the ED . . . or see your psychologist, we will attend to your needs, but we're going to respond in the same way to try to kind of contain some of the splitting.” (P28; social worker, general ED) | |
| Social workers in the ED to facilitate community-based care | 13 | |
| Around-the-clock availability of social workers on staff (on call, evenings) | “We need more social workers in the ED who have a deep and broad understanding of community resources . . . and maybe many [high utilizers] would be diverted from coming to the ED. It helps to know a lot about community resources. Most people's lives don't need therapy. They need a practical solution to an immediate problem.” (P29; social worker, general ED) “If I have a social work colleague who is available to help me with contacting a program at another VA or the non-VA programs in the community . . . making cold calls to other facilities and then trying to get services lined up [for the patient], that is a big help to me.” (P17; psychiatrist, inpatient unit) “What helped us tremendously was to put a social worker in the psychiatric emergency room, so the social worker is in the ED every day from 8 a.m. to 4 p.m., and then we have a social worker on call if we have any specific question.” (P20; psychiatrist, director of psychiatric ED) | |
| Intensive case managementb | 14 | |
| Provide community outreach and coordinate follow-up care | “The [patients with] chronic schizophrenia [are] enrolled in MHICM. We have somebody come see them, make sure they take their medicines, make sure they are compliant, are brought to the clinic. . . . I think that helps with, you know, having the patients coming less often because of course we’re making sure they’re getting their medications.” (P3; psychiatrist, general ED) “We have an H-PACT team for a lot of these guys, and my psychologist . . . she will actually get in the chart before they are expected to come and see her and she will assertively try to make sure they know when their appointment is. The social worker and the H-PACT will do the same. They'll try to reach out and find them and make sure they come to their appointment.” (P11; psychiatrist, associate chief of staff, mental health services) | |
| Flag high utilizers or patients who are at risk of becoming a high utilizer by using committees or predictive analytics | “I'm keeping them on my radar because they're high utilizers and they have frequent needs, and they're not coming to see me in outpatient services, they're coming to the ED and getting admitted a lot . . . if the VA had some kind of a database to track patient caseloads that was integrated into the CPRS.” (P27; supervisory social worker, mental health services) “It would help if we had a high utilizers' committee . . . have certain patients be identified as high utilizers . . . track them and develop some individualized recommendations for each of those patients about what we think are the most important things to do.” (P17; psychiatrist, inpatient unit) |
a
For interviewees, a high utilizer was defined as a patient with mental health issues who is frequently treated in an emergency department or acute inpatient psychiatry unit. P, participant; ED, emergency department; VHA, Veterans Health Administration; CPRS, Computerized Patient Record System
b
Examples include mental health intensive case management (MHICM) for patients with serious mental illness and patient-centered medical homes for homeless patients (H-PACT).
Education, training, and supervision of ED staff.
Participants highlighted the value of more education, training, and supervision of ED staff in evidence-based practices and management of psychiatric disorders. This was perceived by participants as helping reduce utilization of psychiatric emergency services by mitigating staff stigma toward high utilizers.
Interdisciplinary, team-based care.
Participants reported that interdisciplinary, team-based care facilitated better communication within and across services, leading to better care coordination for high utilizers and ultimately helping to reduce unnecessary ED visits. Participants also noted the benefits of this approach for mitigating provider burnout by limiting patients’ potential to split their care providers (that is, view a provider as either working for them or working against them).
Social workers in the ED.
Social workers based in the ED were described as having a crucial role in the care of high utilizers, particularly for connecting patients to community-based services. Within this theme, participants highlighted the value of staffing practices that provide around-the-clock or overnight coverage by psychiatric social workers. Continuous coverage by social workers would ensure that patients admitted outside regular business hours receive appropriate discharge planning and linkage to services on the following morning.
Intensive case management.
Participants reported that intensive case management programs for patients with serious mental illness and patients who are homeless (29) facilitated community outreach to high utilizers of psychiatric emergency services and ensured patients’ compliance with medications and outpatient appointments. In these case management programs, it was suggested to flag high utilizers, or patients who are at risk of becoming high utilizers, using predictive analytics. Individualized treatment plans for these individuals could then be developed to better target the needs of high utilizers.
Discussion
Through our inquiry into the context of care for high utilizers of psychiatric emergency services, this study extended the knowledge base of barriers to and facilitators of reducing service utilization in this population. Despite being able to provide patients with access to behavioral health and social services within an integrated care system (30), the VHA continues to face barriers to reducing utilization of psychiatric emergency services. As debate over health care continues in the United States, consideration of barriers to and facilitators of reducing utilization of psychiatric emergency services in a safety-net provider such as VHA will be critical for health care systems in the private sector, because these systems may be faced with the challenge of serving an increasing number of disenfranchised patients. The lessons learned here, informed by the perspectives of providers across a range of services, may help other health care systems to better target barriers to remove and facilitators to implement to contain health care costs.
Recommendations for Removing Barriers
Patient transiency was found to be a critical barrier to offering continuous outpatient care. Lack of residential stability is associated with poor adherence to mental health aftercare (31). Assertive community outreach may help to combat this problem (32). For example, through the federal government’s Lifeline Assistance Program, most homeless veterans have a mobile phone (33). VHA’s patient-centered medical home for patients who are homeless uses text messaging to increase treatment retention and care adherence in this population (34). Expansion of the Lifeline Assistance Program through a public-private partnership may be a viable alternative for the nonprofit sector (35).
Regarding provider stigma, it has been shown that implicit bias toward patients with chronic mental and substance use disorders negatively affects patient care (36). However, such bias may be reduced with additional training and support. Notably, medical schools have begun to include addiction medicine in their curriculum and emphasize the deleterious effects of stigma (37,38). Furthermore, patients with personality disorders are more likely than patients with other psychiatric disorders to use psychiatric emergency services for their health care (11). Implementing protected time for providers of psychiatric emergency services to engage in team peer support and collaborative care programs with providers from other services may facilitate continuity and coordination of care for these patients (39).
Limited access to addiction pharmacotherapy emerged as a barrier, which is consistent with the nationwide lack of addiction medicine training (40,41). There is ample evidence that medication-assisted treatment for substance use disorders reduces relapse and promotes functional recovery, but cultural and historical factors have hindered its wider acceptance into the current treatment armamentarium (42). New initiatives offer promise for expanding implementation of medication-assisted treatment for high utilizers of psychiatric emergency services (43) and promote a paradigm shift whereby screening and treatment for addictions are integrated with other aspects of health care (44,45).
Limitations on the time allowed for providing psychiatric emergency services did not emerge as a robust theme. This factor should also be considered, given that there is a national movement in health care toward emphasizing community-based care and reductions in length of inpatient stays (46).
Recommendations for Harnessing Facilitators
Continuous access to a psychiatric social worker—24 hours a day, seven days a week—was recommended as a way to provide telehealth services and referrals to community resources and coordination of next-day services for patients who seek care overnight. Through an awareness of local resources in a patient’s community, such a role could address geographic and transportation barriers to accessing outpatient care. In settings with staffing limitations, models of asynchronous telehealth, whereby communication occurs between patients and providers at different times (47), may help to better coordinate discharge to outpatient services. Strengthening of community partnerships with VHA and intra-agency collaborations may also represent important next steps. To better guide development of these partnerships, additional research is needed to determine how availability of community-based services affects use of psychiatric emergency services and other services at the VHA (18).
Intensive case management appears critical for reducing overutilization of psychiatric emergency services, given that recent studies have shown that brief interventions in EDs for substance use and mental health issues are not cost-effective (48). Furthermore, regarding interdisciplinary, team-based care, more research is needed to understand what factors affect the relationships between psychiatric providers within and across services and organizations, given that better communication and coordination may reduce unnecessary ED visits.
Increased education and training in the management of psychiatric disorders may also facilitate better outcomes for high utilizers of psychiatric emergency services. Nonpsychiatric providers are often the first to interact with patients in EDs. As such, their ability to recognize psychiatric symptoms, provide appropriate referrals, and adhere to recovery-oriented care practices is crucial to patients’ satisfaction and well-being (49,50). Recovery-oriented care is focused on the formation of a strong therapeutic alliance and emphasizes patient preferences (28). Although VHA has prioritized the delivery of recovery-oriented care among mental health providers (51), more widespread adoption of recovery-oriented care among nonpsychiatric providers in EDs may increase the likelihood that high utilizers will make a successful transition to outpatient behavioral health services (28).
Finally, implementation of predictive-analytic tools and organization-level high-utilizer committees to create, test, and evaluate policies may promote continuity of care and reduce utilization of psychiatric emergency services. For example, it is estimated that 10% of homeless veterans in PCMHs utilize 65% to 70% of acute care services provided to patients on PCMH teams (29). These teams use clinical aids to develop care plans to address factors that drive these patients’ use of acute care services.
Strengths and Limitations
Regarding strengths, this study complemented descriptive-analytic studies of administrative data (13,14) by identifying factors that are not available or not reliably assessed via administrative records. Furthermore, most studies of high utilizers of psychiatric emergency services have been limited geographically or were focused on private hospitals. This study had the benefit of being a national-level examination that focused on the VHA, an integrated, near-universal health care system and safety-net provider. Regarding limitations, some subpopulations, such as undocumented immigrants, are not included in the VHA patient base, and generalizability of the sample to nonveteran populations is unknown. Second, direct patient perspectives were not solicited in this study. Third, asking directors to refer other providers for the study may have introduced bias into the sample (for example, over- and under-representation of barrier and facilitator themes to reducing overutilization of psychiatric emergency services among high utilizers). Fourth, interviews were conducted approximately three years after the period on which the high-utilizer list was based. If ratios of high utilizers to all users of psychiatric emergency services changed over this time frame, it may have contributed to the lack of differences in the barriers and facilitators identified by providers in the upper and lower quartiles. The stability of utilization of psychiatric emergency services over time, both at the patient and facility levels, should be a target for future research.
Finally, the reported themes reflect the perspectives of participants. Whether removing barriers or harnessing facilitators will have an impact on utilization of psychiatric emergency services requires empirical validation. Furthermore, many high utilizers of psychiatric emergency services struggle with refractory, treatment-resistant disorders and may need frequent psychiatric emergency care. Nonetheless, these findings contribute to hypothesis generation in terms of contextual factors to target in future research on high utilizers of psychiatric emergency services.
Conclusions
This study identified challenges and potential solutions related to reducing utilization of psychiatric emergency services in VHA, a safety-net provider. These results may help other health care systems better target which barriers to remove or which facilitators to implement to contain rising health care costs. Future studies should continue to perform needs assessments among patients and providers to determine where current practices fall short of serving these objectives.
Footnote
The views expressed are the authors’ and do not necessarily reflect those of the Veterans Health Administration.
References
1.
Simonet D: Cost reduction strategies for emergency services: insurance role, practice changes and patients accountability. Health Care Analysis 17:1–19, 2009
2.
Yoon J, Yano EM, Altman L, et al: Reducing costs of acute care for ambulatory care-sensitive medical conditions: the central roles of comorbid mental illness. Medical Care 50:705–713, 2012
3.
Watkins KE, Pincus HA, Paddock S, et al: Care for veterans with mental and substance use disorders: good performance, but room to improve on many measures. Health Affairs (Project Hope) 30:2194–2203, 2011
4.
Wagner TH, Sinnott P, Siroka AM: Mental health and substance use disorder spending in the Department of Veterans Affairs, fiscal years 2000–2007. Psychiatric Services 62:389–395, 2011
5.
Rosenheck RA, Fontana AF: Recent trends in VA treatment of post-traumatic stress disorder and other mental disorders. Health Affairs (Project Hope) 26:1720–1727, 2007
6.
Greenberg G, Rosenheck R: Department of Veterans Affairs National Mental Health Program Performance Monitoring System: Fiscal Year 2007 Report. West Haven, CT, Northeast Program Evaluation Center, 2008
7.
LaCalle E, Rabin E: Frequent users of emergency departments: the myths, the data, and the policy implications. Annals of Emergency Medicine 56:42–48, 2010
8.
Pasic J, Russo J, Roy-Byrne P: High utilizers of psychiatric emergency services. Psychiatric Services 56:678–684, 2005
9.
Ellison JM, Blum NR, Barsky AJ: Frequent repeaters in a psychiatric emergency service. Hospital and Community Psychiatry 40:958–960, 1989
10.
Geller JL, Fisher WH, McDermeit M, et al: The effects of public managed care on patterns of intensive use of inpatient psychiatric services. Psychiatric Services 49:327–332, 1998
11.
Richard-Lepouriel H, Weber K, Baertschi M, et al: Predictors of recurrent use of psychiatric emergency services. Psychiatric Services 66:521–526, 2015
12.
Kent S, Fogarty M, Yellowlees P: A review of studies of heavy users of psychiatric services. Psychiatric Services 46:1247–1253, 1995
13.
Blonigen DM, Macia KS, Bi X, et al: Factors associated with emergency department use among veteran psychiatric patients. Psychiatric Quarterly 88:721–732, 2017
14.
Doran KM, Raven MC, Rosenheck RA: What drives frequent emergency department use in an integrated health system? National data from the Veterans Health Administration. Annals of Emergency Medicine 62:151–159, 2013
15.
Irmiter C, McCarthy JF, Barry KL, et al: Reinstitutionalization following psychiatric discharge among VA patients with serious mental illness: a national longitudinal study. Psychiatric Quarterly 78:279–286, 2007
16.
Noronha SF, Desai PN: Psychiatric emergency services in the Veterans Health Administration: a review. New Directions for Mental Health Services 82:75–84, 1999
17.
Tsai J, Rosenheck RA: Risk factors for ED use among homeless veterans. American Journal of Emergency Medicine 31:855–858, 2013
18.
Brown JF: Psychiatric emergency services: a review of the literature and a proposed research agenda. Psychiatric Quarterly 76:139–165, 2005
19.
Heslop L, Elsom S, Parker N: Improving continuity of care across psychiatric and emergency services: combining patient data within a participatory action research framework. Journal of Advanced Nursing 31:135–143, 2000
20.
Breslow RE, Erickson BJ, Cavanaugh KC: The psychiatric emergency service: where we’ve been and where we’re going. Psychiatric Quarterly 71:101–121, 2000
21.
Plant LD, White JH: Emergency room psychiatric services: a qualitative study of nurses’ experiences. Issues in Mental Health Nursing 34:240–248, 2013
22.
Palinkas LA, Horwitz SM, Green CA, et al: Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Administration and Policy in Mental Health and Mental Health Services Research 42:533–544, 2015
23.
Facility Complexity Levels. Washington, DC, VHA Office of Productivity, Efficiency, and Staffing. http://opes.vssc.med.va.gov/FacilityComplexityLevels/Pages/default.aspx. Accessed June 12, 2017
24.
Hennink MM, Kaiser BN, Marconi VC: Code saturation versus meaning saturation: how many interviews are enough? Qualitative Health Research 27:591–608, 2017
25.
Damschroder LJ, Aron DC, Keith RE, et al: Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science 4:50, 2009
26.
Neal JW, Neal ZP, VanDyke E, et al: Expediting the analysis of qualitative data in evaluation: a procedure for the rapid identification of themes from audio recordings (RITA). American Journal of Evaluation 36:118–132, 2015
27.
Cucciare MA, Coleman EA, Timko C: A conceptual model to facilitate transitions from primary care to specialty substance use disorder care: a review of the literature. Primary Health Care Research and Development 16:492–505, 2015
28.
O’Connell M, Tondora J, Croog G, et al: From rhetoric to routine: assessing perceptions of recovery-oriented practices in a state mental health and addiction system. Psychiatric Rehabilitation Journal 28:378–386, 2005
29.
O’Toole TP, Johnson EE, Aiello R, et al: Tailoring care to vulnerable populations by incorporating social determinants of health: the Veterans Health Administration’s “Homeless Patient Aligned Care Team” program. Preventing Chronic Disease 13:E44, 2016
30.
Longman P: Best Care Anywhere: Why VA Health Care Would Work Better for Everyone, 3rd ed. San Francisco, Berrett-Koehler, 2012
31.
Hershorn M: The elusive population: characteristics of attenders versus non-attenders for community mental health center intakes. Community Mental Health Journal 29:49–57, 1993
32.
Klinkenberg WD, Calsyn RJ: Predictors of receipt of aftercare and recidivism among persons with severe mental illness: a review. Psychiatric Services 47:487–496, 1996
33.
McInnes DK, Sawh L, Petrakis BA, et al: The potential for health-related uses of mobile phones and Internet with homeless veterans: results from a multisite survey. Telemedicine Journal and e-Health 20:801–809, 2014
34.
McInnes DK, Petrakis BA, Gifford AL, et al: Retaining homeless veterans in outpatient care: a pilot study of mobile phone text message appointment reminders. American Journal of Public Health 104(suppl 4):S588–S594, 2014
35.
Ben-Zeev D: Mobile health for all: public-private partnerships can create a new mental health landscape. Journal of Medical Internet Research Mental Health 3:e26, 2016
36.
Corrigan PW, Mittal D, Reaves CM, et al: Mental health stigma and primary health care decisions. Psychiatry Research 218:35–38, 2014
37.
Broyles LM, Binswanger IA, Jenkins JA, et al: Confronting inadvertent stigma and pejorative language in addiction scholarship: a recognition and response. Substance Abuse: Research and Treatment 35:217–221, 2014
38.
Changing the Language of Addiction. Washington, DC, Office of National Drug Control Policy, 2017. https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Memo%20-%20Changing%20Federal%20Terminology%20Regrading%20Substance%20Use%20and%20Substance%20Use%20Disorders.pdf
39.
Stringer B, van Meijel B, Karman P, et al: Collaborative care for patients with severe personality disorders: preliminary results and active ingredients from a pilot study (part I). Perspectives in Psychiatric Care 51:180–189, 2015
40.
Wood E, Samet JH, Volkow ND: Physician education in addiction medicine. JAMA 310:1673–1674, 2013
41.
O’Connor PG, Nyquist JG, McLellan AT: Integrating addiction medicine into graduate medical education in primary care: the time has come. Annals of Internal Medicine 154:56–59, 2011
42.
Reif S, Acevedo A, Garnick DW, et al: Reducing behavioral health inpatient readmissions for people with substance use disorders: do follow-up services matter? Psychiatric Services 68:810–818, 2017
43.
VHA Handbook 1160.01: Uniform Mental Health Services in VA Medical Centers and Clinics. Washington, DC, Department of Veterans Affairs, 2008
44.
Carroll JF, Hall CE, Kearse R, et al: Meeting the treatment needs of veterans with substance use disorders. Alcoholism Treatment Quarterly 34:354–364, 2016
45.
Zubkoff L, Shiner B, Watts BV: Staff perceptions of substance use disorder treatment in VA primary care–mental health integrated clinics. Journal of Substance Abuse Treatment 70:44–49, 2016
46.
Chow WS, Priebe S: Understanding psychiatric institutionalization: a conceptual review. BMC Psychiatry 13:169, 2013
47.
Myers K, Vander Stoep A: i-Therapy: asynchronous telehealth expands access to mental health care and challenges tenets of the therapeutic process. Journal of the American Academy of Child and Adolescent Psychiatry 56:5–7, 2017
48.
Horn BP, Crandall C, Forcehimes A, et al: Benefit-cost analysis of SBIRT interventions for substance using patients in emergency departments. Journal of Substance Abuse Treatment 79:6–11, 2017
49.
Carstensen K, Lou S, Groth Jensen L, et al: Psychiatric service users’ experiences of emergency departments: a CERQual review of qualitative studies. Nordic Journal of Psychiatry 71:315–323, 2017
50.
Blonigen DM, Bui L, Harris AH, et al: Perceptions of behavioral health care among veterans with substance use disorders: results from a national evaluation of mental health services in the Veterans Health Administration. Journal of Substance Abuse Treatment 47:122–129, 2014
51.
VHA Blueprint of Excellence. Washington, DC, US Department of Veterans Affairs, 2014
Information & Authors
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Cover: Decorative Landscape, Hot Morning Sunlight, by Charles Burchfield, 1916. Transparent watercolor on white wove paper with color notations in graphite. Edward W. Root bequest, Munson-Williams-Proctor Arts Institute, Utica, NY. Photo credit: Munson-Williams-Proctor Arts Institute/Art Resource, New York City.
History
Received: 28 June 2017
Revision received: 23 September 2017
Accepted: 20 October 2017
Published online: 1 February 2018
Published in print: April 01, 2018
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Competing Interests
The authors report no financial relationships with commercial interests.
Funding Information
U.S. Department of Veterans Affairs10.13039/100000738: PPO 13-121
This work was supported by VA Health Services Research and Development (HSR&D) (PPO 13-121; principal investigator, Dr. Blonigen). Dr. Blonigen and Dr. Heinz were supported by Career Development Awards from VA Clinical Science Research and Development and VA Rehabilitation Research and Development, respectively. Dr. Bi was supported by the VA Office of Academic Affiliations (TPP 62-500) and the VA HSR&D Service in conjunction with a VA HSR&D Advanced Fellowship Program (TPP 97-006). Dr. Timko and Dr. Wagner were supported by Research Career Scientist awards from VA HSR&D (RCS 00-001; principal investigator, Dr. Timko).Metrics & Citations
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