Mobile Psychiatric Treatment Team | An Alternative to Emergency Room Boarding and Inpatient Psychiatric Hospitalization

Working on several psychiatric evaluation teams across San Diego in the Emergency Room, I was tasked with evaluating, not treating patients in psychiatric crisis. Patients would languish in the ER often for days while awaiting inpatient psychiatric hospitalization because they were too acute for outpatient treatment. Working with all of the inpatient psychiatric hospitals in the county it became a joke when calling for beds, as the answer was often “No.” After several days, the patient’s crisis would typically resolve and they would discharge, without ever receiving any psychiatric treatment.

I began to work on this project because I felt helpless as I was unable to help the patients and their families, and I began to question if there was anything else, I could do. There was a conflict in what I observed in the ER staff I worked who lacked empathy and compassion for patients in psychiatric despair. I knew that patients were not getting the care they needed, and I felt helpless and decided to develop a resolution.

PROBLEM STATEMENT |How might we help people in a behavioral health crisis in the emergency room obtain mental health care, stabilize and discharge to appropriate levels of care within 24-hours.

PROJECT PLAN

EMPATHIZE

ER physician’s and nurse’s inability to cope with the needs of patients with mental illness. 

Lack of mental health training, long boarding times and general discomfort has been cited by ER physicians, and nurses, thusly, inadequate care during a crisis only impacts the initial crisis. 

From the patient’s perspective, ERs are overstimulating, lack privacy, increase stress, increase stigma, rights removed, which ultimately compound the reason for the admission to the ER. 

Patients are typically designated a bed or room, monitored by a sitter or security at their bedside and have had their clothes and belongings removed. 

Some patients wait for days for a bed to become available, and others are discharged home once the crisis passes. The extended length of stays was found to be stressful for the patient and the family as well as the ER staff, which contributes to the disparity in treatment. 

DEFINE

People experiencing a mental health crisis often seek help in an emergency room (ER) as their options are limited due to lack of available outpatient treatment and inpatient psychiatric beds.

Emergency rooms are already overcrowded, and many of the providers in the ER are not psychiatrically trained to provide care or de-escalate the crisis. 

The ER is not a therapeutic healing environment for individuals in acute mental health crisis. 

There is a marked disparity in the treatment of individuals presenting with mental health issues versus medical issues. 

ER boarding has been significant since the 1980s due to decreasing inpatient psychiatric beds, poor access to outpatient mental health treatment as well as lack of funding for these services. 

  • The ER has been the main point of entry for psychiatric emergencies and leads to ER boarding. 
  • Inpatient psychiatric facilities and beds have decreased leading to inadequate access to inpatient levels of care.

IDEATE

PROTOTYPE

To address ER boarding, first we need to develop a unit in the hospital to get people out of the ER setting. 

Need to develop a unit for the MPTT to treat the patient within the hospital setting. 

  • Group milieu setting
  • Lounge chairs (not beds). 
  • Patients may wear their own clothes. 
  • Staff working with patients on the unit for 23 hours 59 minutes.
  • Monitoring for safety. 

TEST

  • Propose a 1 year MPTT pilot in an ER in San Diego, CA.
  • Develop partnerships with local Hospital ERs & County agencies.

SHARE

Developing a MPTT Unit within the hospital setting to provide psychiatric crisis intervention designed to de-escalate the crisis by providers who are trained in crisis intervention and safety management. 

After patients are stabilized medically in the ER, they will be transferred to the MPTT Unit and will be offered treatment and then dispositioned within 24 hours. 

Decreasing the disparity of patients seeking mental health care by ensuring acute mental health treatment in a non-stigmatizing setting. 

Treating 1,825 people in the first year of the program in one hospital setting

SUMMARY

The MPTT will need to develop partnerships between with local hospitals and County agencies. 

  • Obtain funding. 
  • Develop a MPTT Unit within the hospital setting. 
  • Develop the policies and procedures and hire the team.
  • Implementation & Testing

The mental health system needs to address the problem of people with mental health conditions being detained in the ER without care, but we have been stuck in the norms of a system that no longer fits needs of the community. 

This innovative 23-hour crisis interventions will provide a cost savings to hospitals, insurance companies and consumers.

It is time to change the trajectory of care and implement the Mobile Psychiatric Treatment Team in San Diego, CA.

  • Treating the patient’s immediate mental health needs.
  • 24-hour Crisis Intervention
  • Patients linked to community for continued services.
  • Patients will have access to team for up to 30 days post discharge.
  • Decreased reliance upon inpatient hospitals.
  • Decreased ER boarding.
  • Decreased 30-day readmissions.
  • Increased Equity in Mental Health treatment.
  • Decreased Stigma.
  • Cost Savings to Consumers, Hospitals and Insurance Companies

CONTACT

Interested in learning more about this project? Contact Dr. Lisa Krekler to learn more via email: krekler@usc.edu

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