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Simpson SA, Takeshita J. Better Science for Better Emergency Psychiatry: A New Section for JACLP. J Acad Consult Liaison Psychiatry 2023; 64:103-105. [PMID: 36764485 DOI: 10.1016/j.jaclp.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
| | - Junji Takeshita
- Department of Psychiatry, University of Hawaii John A. Burns School of Medicine and The Queen's Medical Center, Honolulu, HI
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2
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Oblath R, Herrera CN, Were LPO, Syeda HS, Duncan A, Ferguson T, Kalesan B, Perez DC, Taglieri J, Borba CPC, Henderson DC. Long-Term Trends in Psychiatric Emergency Services Delivered by the Boston Emergency Services Team. Community Ment Health J 2023; 59:370-380. [PMID: 36001197 PMCID: PMC9399566 DOI: 10.1007/s10597-022-01015-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 08/04/2022] [Indexed: 01/25/2023]
Abstract
Rising psychiatric emergency department (ED) presentations pose significant financial and administrative burdens to hospitals. Alternative psychiatric emergency services programs have the potential to alleviate this strain by diverting non-emergent mental health issues from EDs. This study explores one such program, the Boston Emergency Services Team (BEST), a multi-channel psychiatric emergency services provider intended for the publicly insured and uninsured population. BEST provides evaluation and treatment for psychiatric crises through specialized psychiatric EDs, a 24/7 hotline, psychiatric urgent care centers, and mobile crisis units. This retrospective review examines the sociodemographic and clinical characteristics of 225,198 BEST encounters (2005-2016). Of note, the proportion of encounters taking place in ED settings decreased significantly from 70 to 58% across the study period. Findings suggest that multi-focal, psychiatric emergency programs like BEST have the potential to reduce the burden of emergency mental health presentations and improve patient diversion to appropriate psychiatric care.
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Affiliation(s)
- Rachel Oblath
- Department of Psychiatry, Boston Medical Center, Boston, USA. .,BEST Partnership for Behavioral Health, Racial, and Social Justice, Boston Medical Center, Boston, USA.
| | - Carolina N Herrera
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, USA
| | - Lawrence P O Were
- Department of Health Sciences, Boston University's College of Health and Rehabilitation Sciences: Sargent College, Boston, USA.,Department of Global Health, Boston University School of Public Health, Boston, USA
| | - Haniya Saleem Syeda
- Department of Psychiatry, Boston Medical Center, Boston, USA.,BEST Partnership for Behavioral Health, Racial, and Social Justice, Boston Medical Center, Boston, USA
| | - Alison Duncan
- Department of Psychiatry, Boston Medical Center, Boston, USA.,BEST Partnership for Behavioral Health, Racial, and Social Justice, Boston Medical Center, Boston, USA.,Boston University School of Medicine, Boston, USA
| | - Tasha Ferguson
- Department of Psychiatry, Boston Medical Center, Boston, USA.,BEST Partnership for Behavioral Health, Racial, and Social Justice, Boston Medical Center, Boston, USA.,Boston University School of Medicine, Boston, USA
| | - Bindu Kalesan
- Department of Medicine, Center for Clinical Translational Epidemiology and Comparative Effectiveness Research, Preventive Medicine and Epidemiology, Boston University School of Medicine, Boston, USA
| | - Daisy C Perez
- Department of Psychiatry, Boston Medical Center, Boston, USA.,BEST Partnership for Behavioral Health, Racial, and Social Justice, Boston Medical Center, Boston, USA
| | - Joan Taglieri
- Department of Psychiatry, Boston Medical Center, Boston, USA.,Department of Psychiatry, Cambridge Health Alliance, Cambridge, USA.,Boston University School of Medicine, Boston, USA
| | - Christina P C Borba
- Department of Psychiatry, Boston Medical Center, Boston, USA.,BEST Partnership for Behavioral Health, Racial, and Social Justice, Boston Medical Center, Boston, USA.,Boston University School of Medicine, Boston, USA
| | - David C Henderson
- Department of Psychiatry, Boston Medical Center, Boston, USA.,BEST Partnership for Behavioral Health, Racial, and Social Justice, Boston Medical Center, Boston, USA.,Boston University School of Medicine, Boston, USA
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More than Suicide: Mortality after Emergency Psychiatric Care and Implications for Practice. J Acad Consult Liaison Psychiatry 2022; 63:354-362. [PMID: 35017123 DOI: 10.1016/j.jaclp.2021.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/08/2021] [Accepted: 12/24/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Emergency departments (EDs) provide vital mental health services. ED patients with behavioral health presentations, particularly suicidal ideation, are at increased risk of death by suicide, medical illness, trauma, or overdose. Causes of death for patients who receive specialty emergency psychiatric services remain undescribed. OBJECTIVE We describe the incidence and cause of death after care in a psychiatric emergency service (PES). METHODS Mortality data were obtained for all adult patients treated in a safety net ED from April 2016 to June 2020. Causes of death were categorized as medical, external (accidents, overdoses, and homicide), or suicide and compared between PES patients and ED patients who were not treated in the PES. Correlates of mortality were described for PES patients. RESULTS We analyzed 164,422 encounters including 6,063 PES visits. Mortality in the 30 days after discharge was 0.3% among PES patients and 0.6% among medical ED patients. At both 30 and 365 days, PES patients were more likely to die by suicide than were medical ED patients, and ED patients were more likely to die by medical causes. Among PES patients who died within 365 days, 46% died by medical causes, 32% by external causes, and 23% by suicide. In multivariable analyses, age was associated with all-cause, medical, and external mortality after a PES visit; opioid and stimulant use disorders were associated with all-cause and external mortality. CONCLUSIONS Most patients who die after receiving emergency psychiatric care die by medical and external causes such as accidents, overdose, and homicide. Patients who are older and have opioid or stimulant use disorders are at higher risk of non-suicide mortality. We propose interventions to re-imagine emergency psychiatric care and address non-suicide mortality among psychiatric patients treated in emergency and crisis settings.
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Simpson SA, Loh RM, Cabrera M, Cahn M, Gross A, Hadley A, Lawrence RE. The Impact of the COVID-19 Pandemic on Psychiatric Emergency Service Volume and Hospital Admissions. J Acad Consult Liaison Psychiatry 2021; 62:588-594. [PMID: 34058432 PMCID: PMC8163698 DOI: 10.1016/j.jaclp.2021.05.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/06/2021] [Accepted: 05/06/2021] [Indexed: 02/07/2023]
Abstract
Background During the COVID-19 pandemic, there have been an increasing number of emergency department visits for behavioral health reasons, even as overall emergency department volumes have decreased. The impact of the pandemic and related public health interventions on specialized psychiatric emergency services has not been described. These services provide high-intensity care for severely ill patients who are likely to be homeless and underserved. Objective We describe the change in total volume and psychiatric hospitalization rates among three psychiatric emergency services across the United States. Methods Changes in volumes and hospitalization were assessed for statistical significance using a seasonal autoregressive integrated moving average with exogenous factors model from January 2018 to December 2020. Results The pandemic's impact on volumes and hospitalization varied by site. In Denver (CO), there was a statistically significant 9% decrease in overall volumes, although an 18% increase in hospitalizations was not significant. In New York City (NY), there was a significant 7% decrease in volumes as well as a significant 6% decrease in hospitalizations. In Portland (OR), volumes decreased by 4% and hospitalizations increased by 6% although differences did not reach statistical significance. Conclusions There has been a decrease in volume at these services after the pandemic, but there are substantial variations in the magnitude of change and demand for hospitalization by region. These findings suggest a need to understand where patients in crisis are seeking care and how systems of care must adapt to changing utilization in the pandemic era.
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Affiliation(s)
- Scott A Simpson
- Department of Behavioral Health Services, Denver Health, Denver, CO.
| | - Ryan M Loh
- Department of Behavioral Health Services, Denver Health, Denver, CO
| | | | - Megan Cahn
- Legacy Research Institute, Legacy Health, Portland, OR
| | - Anne Gross
- Department of Psychiatry, Oregon Health Sciences University, Portland, OR
| | - Allison Hadley
- Department of Psychiatry, Oregon Health Sciences University, Portland, OR
| | - Ryan E Lawrence
- Department of Psychiatry, Columbia University Medical Center, New York City, NY
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Stamy C, Shane DM, Kannedy L, Van Heukelom P, Mohr NM, Tate J, Montross K, Lee S. Economic Evaluation of the Emergency Department After Implementation of an Emergency Psychiatric Assessment, Treatment, and Healing Unit. Acad Emerg Med 2021; 28:82-91. [PMID: 32869891 DOI: 10.1111/acem.14118] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/04/2020] [Accepted: 08/21/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We sought to evaluate the impact of an emergency psychiatric assessment, treatment, and healing (EmPATH) unit on emergency department (ED) revenue, psychiatric boarding time, and length of stay (LOS). METHODS We conducted a before-and-after economic evaluation of a single academic midwestern ED (60,000 annual visits) for all adult (≥18 years) patients before (December 2017-May 2018) and after (December 2018-May 2019) opening an EmPATH unit. These are outpatient hospital-based programs that provide emergent treatment and stabilization for mental health emergencies from ED patients. The Holt-Winters method was used to forecast pre-EmPATH expected ED levels of patients leaving without being seen, leaving against medical advice, eloping, or being transferred using 3 years of ED visits. ED revenues were calculated by finding the difference of pre-EmPATH expected and post-EmPATH observed values and multiplying by the revenue per visit. ED boarding time and LOS were obtained from the hospital's electronic medical record. RESULTS There were 23,231 and 23,336 ED visits evaluated during the pre- and post-EmPATH unit periods. The ED generated an estimated additional $404,954 in the 6 months and $861,065 annually after the implementation of the EmPATH unit. The median (interquartile range [IQR]) psychiatric boarding time decreased from 212 (119-536) minutes to 152 (86-307) minutes (mean difference = 189 minutes, 95% confidence interval [CI] = 150 to 228 minutes) and median (IQR) LOS decreased from 351 (204-631) minutes to 334 (212-517) minutes (mean difference = 114 minutes, 95% CI = 87 to 143 minutes). CONCLUSION The EmPATH unit had a positive impact on ED revenue and decreased ED boarding time and LOS for psychiatric patients.
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Affiliation(s)
- Chris Stamy
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Dan M. Shane
- the Department of Health Management and PolicyUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Levi Kannedy
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Paul Van Heukelom
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Nicholas M. Mohr
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
- the Division of Critical Care Department of AnesthesiaUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Jodi Tate
- and the Department of Psychiatry University of Iowa Carver College of Medicine Iowa City IAUSA
| | - Kelsey Montross
- and the Department of Psychiatry University of Iowa Carver College of Medicine Iowa City IAUSA
| | - Sangil Lee
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
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6
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Fleury MJ, Grenier G, Bamvita JM, Ferland F. Typology of patients who use emergency departments for mental and substance use disorders. BJPsych Open 2020; 6:e59. [PMID: 32489163 PMCID: PMC7345525 DOI: 10.1192/bjo.2020.39] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Identifying profiles of people with mental and substance use disorders who use emergency departments may help guide the development of interventions more appropriate to their particular characteristics and needs. AIMS To develop a typology for the frequency of visits to the emergency department for mental health reasons based on the Andersen model. METHOD Questionnaires were completed by patients who attended an emergency department (n = 320), recruited in Quebec (Canada), and administrative data were obtained related to sociodemographic/socioeconomic characteristics, mental health diagnoses including alcohol and drug use, and emergency department and mental health service utilization. A cluster analysis was performed, identifying needs, predisposing and enabling factors that differentiated subclasses of participants according to frequency of emergency department visits for mental health reasons. RESULTS Four classes were identified. Class 1 comprised individuals with moderate emergency department use and low use of other health services; mostly young, economically disadvantaged males with substance use disorders. Class 2 comprised individuals with high emergency department and specialized health service use, with multiple mental and substance use disorders. Class 3 comprised middle-aged, economically advantaged females with common mental disorders, who made moderate use of emergency departments but consulted general practitioners. Class 4 comprised older individuals with multiple chronic physical illnesses co-occurring with mental disorders, who made moderate use of the emergency department, but mainly consulted general practitioners. CONCLUSIONS The study found heterogeneity in emergency department use for mental health reasons, as each of the four classes represented distinct needs, predisposing and enabling factors. As such, interventions should be tailored to different classes of patients who use emergency departments, based on their characteristics.
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Affiliation(s)
- Marie-Josée Fleury
- Department of Psychiatry, McGill University; and Douglas Mental Health University Institute Research Centre, Quebec, Canada
| | - Guy Grenier
- Douglas Mental Health University Institute Research Centre, Quebec, Canada
| | - Jean-Marie Bamvita
- Douglas Mental Health University Institute Research Centre, Quebec, Canada
| | - Francine Ferland
- School of Social Work, Laval University; and Addiction Rehabilitation Centre, University Integrated Health and Social Services Centre - Capitale-Nationale, Quebec, Canada
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Fleury MJ, Grenier G, Farand L, Ferland F. Use of Emergency Rooms for Mental Health Reasons in Quebec: Barriers and Facilitators. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2020; 46:18-33. [PMID: 30074113 DOI: 10.1007/s10488-018-0889-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
This study explored barriers and facilitators in mental health (MH) patient management in four Quebec (Canada) emergency rooms (ERs) that used different operational models. Forty-nine stakeholders (managers, physicians, ER and addiction liaison team members) completed semi-structured interviews. Barriers and facilitators affecting patient management emanated from health systems, patients, organizations, and from professionals themselves. Effective management of MH patients requires ER access to a rich network of outpatient, community-based MH services; integration of general and psychiatric ERs; on-site addiction liaison teams; round-the-clock ER staffing, including psychiatrists; ER staff training in MH; and adaptation to frequent and challenging ER users.
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Affiliation(s)
- Marie-Josée Fleury
- Department of Psychiatry, McGill University, 1033 Pine Avenue West, Montreal, QC, H3A 1A1, Canada. .,Douglas Mental Health University Institute Research Centre, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada.
| | - Guy Grenier
- Douglas Mental Health University Institute Research Centre, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada
| | - Lambert Farand
- Department of Health Administration, Policy and Evaluation School of Public Health, University of Montreal, Montreal, QC, Canada
| | - Francine Ferland
- School of Social Work, Laval University, Quebec City, QC, Canada
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Mongelli F, Georgakopoulos P, Pato MT. Challenges and Opportunities to Meet the Mental Health Needs of Underserved and Disenfranchised Populations in the United States. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2020; 18:16-24. [PMID: 32047393 PMCID: PMC7011222 DOI: 10.1176/appi.focus.20190028] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
This article investigates the gap in access to and quality of mental health care in the United States. This work first discusses how minority populations are most affected by the treatment gap. It summarizes recent literature on the topic for better understanding the needs of psychiatrically underserved and disenfranchised populations and the causes of mental health disparities. It reviews some of the barriers to behavioral health care, including lack of insurance coverage, lack of community-based interventions, unequal access to evidence-based practices, stigma, mental health workforce shortages, and geographical maldistribution of providers. Second, it reviews opportunities to address these disparities. The article provides examples of effective interventions that researchers worldwide have already implemented to address the gap of mental health services within the collaborative care model and global mental health initiatives. Telepsychiatry and improvements in training of the mental health workforce are also listed as useful implementations to overcome the treatment gap for patients seeking mental health care.
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Affiliation(s)
- Francesca Mongelli
- Institute for Genomic Health, Department of Psychiatry, College of Medicine (Pato), and Institute for Genomic Health (Georgakopoulos), SUNY Downstate, Brooklyn, NY; Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy (Mongelli)
| | - Penelope Georgakopoulos
- Institute for Genomic Health, Department of Psychiatry, College of Medicine (Pato), and Institute for Genomic Health (Georgakopoulos), SUNY Downstate, Brooklyn, NY; Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy (Mongelli)
| | - Michele T Pato
- Institute for Genomic Health, Department of Psychiatry, College of Medicine (Pato), and Institute for Genomic Health (Georgakopoulos), SUNY Downstate, Brooklyn, NY; Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy (Mongelli)
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9
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Fleury MJ, Grenier G, Farand L, Ferland F. Reasons for Emergency Department Use among Patients with Mental Disorders. Psychiatr Q 2019; 90:703-716. [PMID: 31342253 DOI: 10.1007/s11126-019-09657-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Disproportionate use of emergency departments (EDs) by patients with mental disorders suggests the need to evaluate factors associated with ED use. Based on the Andersen Behavioral model, this mixed-method study identified the contributions of predisposing, enabling and needs factors in ED use among 328 patients with mental disorders. We hypothesised that ED use for mental health (MH) reasons would be most strongly associated with need factors. The study was conducted in four EDs located in different territories of Quebec (Canada). ED teams assisted with patient recruitment. Participants completed a questionnaire including a qualitative component on reasons for using the ED and assessments of ED and MH services. Data were organised according to the Andersen model, and analysed thematically. ED users were generally single, with low socioeconomic status and inadequate knowledge of MH services (predisposing factors). Most had a regular source of care which facilitated ED referrals (enabling factors); although inadequate access to outpatient care contributed to ED use. Needs factors were the primary motivators in ED use among patients with mental disorders, especially self-rated importance of problems, and MH diagnoses including suicidal ideation/attempts, depression, anxiety, and substance use disorders. Results confirmed our hypothesis that ED visits were more strongly related to needs factors. The mixed methodology reinforced the importance of predisposing and enabling factors in ED use, particularly in more complex cases. Various strategies (e.g. shared care, recruitment of addiction liaison nurses for SUD screening) are suggested for improving access to other resources and reducing non-urgent ED use.
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Affiliation(s)
- Marie-Josée Fleury
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada. .,Douglas Mental Health University Institute Research Centre, Montreal, Quebec, Canada. .,Douglas Hospital Research Centre, 6875 LaSalle Blvd. Montreal, Quebec, H4H 1R3, Canada.
| | - Guy Grenier
- Douglas Mental Health University Institute Research Centre, Montreal, Quebec, Canada
| | - Lambert Farand
- Department of Health Administration, Policy and Evaluation, School of Public Health, University of Montreal, Montreal, Quebec, Canada
| | - Francine Ferland
- School of Social Work, Addiction Rehabilitation Center, National Capital University Integrated Health and Social Services Center, Laval University, Quebec City, Quebec, Canada
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10
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Kromka W, Simpson S. A Narrative Review of Predictors of Adult Mental Health Emergency Department Return Visits and Interventions to Reduce Repeated Use. J Emerg Med 2019; 57:671-682. [DOI: 10.1016/j.jemermed.2019.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 06/10/2019] [Accepted: 08/01/2019] [Indexed: 11/15/2022]
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Fleury MJ, Grenier G, Farand L. Satisfaction with Emergency Departments and Other Mental Health Services among Patients with Mental Disorders. ACTA ACUST UNITED AC 2019; 14:43-54. [PMID: 31017865 PMCID: PMC7008685 DOI: 10.12927/hcpol.2019.25793] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background Few studies have investigated satisfaction with emergency departments (EDs) among patients with mental health (MH) issues. This study evaluated the use of and satisfaction with EDs and other MH services among 328 patients with MH disorders, as well as specific characteristics of patient satisfaction and dissatisfaction. Methods A mixed-methods study was conducted in four EDs located in different administrative healthcare regions of Quebec (Canada). Results Patients were highly satisfied with staff attitudes in EDs and other MH services (i.e., hospital in-patient services, outpatient services, community organizations). Major sources of dissatisfaction were the information received in EDs concerning community services and the physical environment or climate in EDs and other MH services. Conclusion Dissatisfaction with services may be reduced by extending hours of operation in MH services; promoting collaboration between psychiatrists, family physicians and other primary care providers; further integrating EDs with other healthcare services; and improving the characteristically austere and restrictive atmosphere in EDs.
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Affiliation(s)
- Marie-Josée Fleury
- Professor, Department of Psychiatry, McGill UniversityResearcher, Douglas Mental Health University Institute Research CentreMontreal, QC
| | - Guy Grenier
- Research AssociateDouglas Mental Health University Institute Research CentreMontreal, QC
| | - Lambert Farand
- Associate ProfessorDepartment of Health Administration, Policy and EvaluationSchool of Public Health, University of MontrealMontreal, QC
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12
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Patient-Centered Values and Experiences with Emergency Department and Mental Health Crisis Care. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2019; 45:611-622. [PMID: 29383464 DOI: 10.1007/s10488-018-0849-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Little is known about what patients value in psychiatric crisis services or how they compare community-based services with those received in the emergency department. Three focus groups (n = 27) were held of participants who had received psychiatric crisis services in emergency departments or a community mental health center. Participants described care experiences and preferences. Focus groups were audio recorded, transcribed, and coded using a value-based lens. Themes included appreciation for feeling respected, basic comforts, and shared decision-making as foundations of quality care. Participants preferred the community mental health center. Research should address long-term outcomes to motivate change in psychiatric crisis care.
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The impact of different liaison psychiatry models on the emergency department: A systematic review of the international evidence. J Psychosom Res 2019; 119:53-64. [PMID: 30947819 DOI: 10.1016/j.jpsychores.2019.01.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 01/13/2019] [Accepted: 01/17/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This review aimed to evaluate the current evidence for what impact different Liaison Psychiatry (LP) services are having on Emergency Departments (ED). Mental Health (MH) problems contribute to 12 million annual US ED attendances and 5% in the UK. METHODS Databases were searched for articles describing LP services for adult MH patients attending EDs which reported ED care-related outcomes, published since 2000. Articles were screened and relevant articles quality assessed and narratively synthesized. RESULTS 3653 articles were identified and 17 included in the review. Study designs were overall of poor-moderate quality, using retrospective before-and-after study designs. LP services were categorized into four models. Models with MH personnel integrated into the ED team or triage reduced patient waiting time to be seen, may reduce patients leaving without being seen and have high staff satisfaction. Co-located MH space or personnel reduced patient waiting times. Care agreements with existing psychiatry teams don't affect waiting times or ED length of stay. Transferring patients to external services reduces patients' time in the ED. There is insufficient evidence about patient satisfaction, costs, and onward care. CONCLUSIONS Waiting times are shortened by MH personnel integrated into the ED and are more satisfactory to staff than other LP models. The involvement of a psychiatrist in the LP team improves the care quality. All models may improve safety for patients but most evaluations are of poor quality and therefore there is still insufficient evidence to recommend one service model over another and further robust research is required.
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Moulin A, Evans EJ, Xing G, Melnikow J. Substance Use, Homelessness, Mental Illness and Medicaid Coverage: A Set-up for High Emergency Department Utilization. West J Emerg Med 2018; 19:902-906. [PMID: 30429919 PMCID: PMC6225935 DOI: 10.5811/westjem.2018.9.38954] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 09/21/2018] [Accepted: 09/27/2018] [Indexed: 11/11/2022] Open
Abstract
Introduction Frequent users of emergency departments (ED) account for 21–28% of all ED visits nationwide. The objective of our study was to identify characteristics unique to patients with psychiatric illness who are frequent ED users for mental health care. Understanding unique features of this population could lead to better care and lower healthcare costs. Methods This retrospective analysis of adult ED visits for mental healthcare from all acute care hospitals in California from 2009–2014 used patient-level data from California’s Office of Statewide Health Planning and Development. We calculated patient demographic and visit characteristics for patients with a primary diagnosis of a mental health disorder as a percentage of total adult ED visits. Frequent ED users were defined as patients with more than four visits in a 12-month period. We calculated adjusted rate ratios (aRR) to assess the association between classification as an ED frequent user and patient age, sex, payer, homelessness, and substance use disorder. Results In the study period, 846,867 ED visits for mental healthcare occurred including 238,892 (28.2%) visits by frequent users. Patients with a primary mental health diagnosis and a co-occurring substance use diagnosis in the prior 12 months (77% vs. 37%, aRR [4.02], 95% confidence interval [CI] [3.92–4.12]), homelessness (2.9% vs 1.1%, odds ratio [1.35], 95% [CI] [1.27–1.43]) were more likely to be frequent users. Those covered by Medicare (aRR [3.37], 95% CI [3.20–3.55]) or the state’s Medicaid program Medi-Cal (aRR [3.10], 95% CI [2.94–3.25]) were also more likely to be frequent users compared with those with private insurance coverage. Conclusion Patients with substance use disorders, homelessness and public healthcare coverage are more likely to be frequent users of EDs for mental illness. Substance use and housing needs are important factors to address in this population.
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Affiliation(s)
- Aimee Moulin
- University of California, Davis, Department of Emergency Medicine, Department of Psychiatry, Davis, California
| | - Ethan J Evans
- University of California, Davis, Center for Healthcare Policy and Research, Davis, California
| | - Guibo Xing
- University of California, Davis, Center for Healthcare Policy and Research, Davis, California
| | - Joy Melnikow
- University of California, Davis, Center for Healthcare Policy and Research, Davis, California.,University of California, Davis, Department of Family and Community Medicine, Davis, California
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15
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Simpson SA, Monroe C. Implementing and Evaluating a Standard of Care for Clinical Evaluations in Emergency Psychiatry. J Emerg Med 2018; 55:522-529.e2. [DOI: 10.1016/j.jemermed.2018.07.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/06/2018] [Accepted: 07/11/2018] [Indexed: 11/28/2022]
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Simpson SA, Pasic J. The Peregrinating Psychiatric Patient in the Emergency Department. West J Emerg Med 2016; 17:600-6. [PMID: 27625725 PMCID: PMC5017845 DOI: 10.5811/westjem.2016.6.30179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 05/24/2016] [Accepted: 06/06/2016] [Indexed: 12/29/2022] Open
Abstract
Many emergency department (ED) psychiatric patients present after traveling. Although such travel, or peregrination, has long been associated with factitious disorder, other diagnoses are more common among travelers, including psychotic disorders, personality disorders, and substance abuse. Travelers’ intense psychopathology, disrupted social networks, lack of collateral informants, and unawareness of local resources complicate treatment. These patients can consume disproportionate time and resources from emergency providers. We review the literature on the emergency psychiatric treatment of peregrinating patients and use case examples to illustrate common presentations and treatment strategies. Difficulties in studying this population and suggestions for future research are discussed.
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Affiliation(s)
- Scott A Simpson
- University of Colorado, Denver, School of Medicine, Department of Psychiatry, Aurora, Colorado; Denver Health Medical Center, Department of Psychiatry, Denver, Colorado
| | - Jagoda Pasic
- University of Washington School of Medicine, Department of Psychiatry, Seattle, Washington
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