Addressing the Mental Health Crisis in Emergency Departments

Executive Summary

We came across an interesting article on the Health Affairs website and wanted to share some insights from it with the Mental Health Community. We are interested in generating some discussion on this topic. Visit the Community to join the conversation.

One in eight visits to the ED is related to a mental health or a substance abuse issue, a number that has been increasing each year for the past decade and is hitting emergency departments (EDs) particularly hard. Despite the fact that EDs are one of the last remaining safety nets in the community, they remain poorly equipped to address these individuals’ needs because of a variety of issues that are geared more towards acute physical issues rather than mental health. The Institute for Healthcare Improvement (IHI) and the Well Being Trust have partnered to try to integrate mental health care into the ED. The following six key themes emerged from their research:

  1. A cycle of fear among providers, patients, and families contributes to a negative culture and poor quality and experience of care.
  2. There is a striking lack of standardization and implementation of effective care processes within the ED.
  3. ED teams lack the right personnel with the right processes and skills to provide effective care for individuals with mental health and substance abuse needs.
  4. Families are excluded in the current system of care in EDs.
  5. Care settings do not coordinate or communicate across a community.
  6. Programs to divert patients from the ED can be very effective at providing high-quality care while reducing the burden on EDs but can perpetuate separate medical and mental health systems. Depending on the needs and size of the population served, existing services, and available resources, they may not yield a sufficient return on the substantial, initial investment.

Based on the above themes and gaps, they have identified five key components of a new approach to improve care in the ED and upstream. This approach aims to improve patient outcomes, the experience of care, and staff safety, while decreasing avoidable, repeat ED visits for individuals with mental health and substance abuse issues. The approaches are outlined below.


1. Build And Leverage Partnerships With Community-Based Services

Health systems must understand the landscape of mental health, substance use, and social service organizations in their community. This includes the populations served, available services and resources, and the competing incentives and payment systems at play. Additionally, many EDs do not know where some of their patients are coming from in the community. While many patients self-present or may be brought in by law enforcement, others are referred by primary care or outpatient behavioral health services – and many could be better served at a less intense level of care. While an ED visit may be appropriate for some, such as those who are in imminent danger to themselves or other people, others could be managed safely in a less restrictive setting.

2. Coordinate And Communicate Between The ED And Other Health Care And Community-Based Services

Different care settings often treat each interaction with a patient as a discrete episode with no continuity or communication with other providers and family members about the past or what happens after the patient leaves their care. There are several different models to learn from to improve coordination of care for individuals with mental health and substance abuse needs, with community health workers, navigators, health coaches, and peers.

3. Standardize Processes, From ED Intake To Discharge, For A Range Of Mental Health And Substance Abuse Issues

ED teams are often operating without clear guidance or protocols for a range of behavioral health conditions. Guidelines exist for key issues such as comprehensive assessment, triage, diagnosis, verbal de-escalation, psychopharmacology, and avoidance of coercion, seclusion, and restraints; however, these standards need to be more widely disseminated and adopted. Additionally, teams need to develop standardization and protocols wherever they currently may not exist.

4. Engage And Equip Patients, Family Members, and Caregivers To Support Self-Management

Patients and their family members and caregivers too frequently do not receive any information about what is happening to them or their loved one. They need tools to rely on, information, support, and hope.

5. Create A Trauma-Informed Culture Among ED Staff

The current culture in many EDs is not conducive to supporting individuals with mental health issues. Some providers do not see behavioral health as part of their scope of work. To improve care, EDs must work to create a trauma-informed culture to provide a better environment for individuals with behavioral health needs.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), trauma-informed care:

  1. Realizes the widespread impact of trauma and understands potential paths for recovery;
  2. Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;
  3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and
  4. Seeks to actively resist re-traumatization.