When an ambulance is called to the scene of a crisis in the United States, no matter the type, there are a limited number of places it can go next. Emergency ground ambulance services can transport to a hospital, skilled nursing facility, or a dialysis center. More often than not, they head to a nearby hospital emergency department (ED). If they don’t go to one of the Centers for Medicare & Medicaid Services (CMS) predetermined locations, they won’t get paid, says Michael Allen, M.D., medical director of the Rocky Mountain Crisis Partners, the hub of Colorado Crisis Services. “It’s a little known fact that this payment methodology has been the crisis system’s primary driver.” Dr. Allen is hopeful that’s about to change with the new CMS payment model ET3, which stands for Emergency Triage, Treat, and Transport.
In March, CMS gave ambulance services temporary regulatory waivers during the pandemic, allowing them to transport to places aside from the hospital when not medically necessary. Destinations include community mental health centers, doctor’s offices, urgent care facilities, ambulatory surgery centers, and federally qualified health centers (FQHCs), and any location that performs dialysis services when an End-Stage Renal Disease facility isn’t available. This flexibility, notes Dr. Allen, is much needed and not just during the COVID-19 public health crisis, but the waivers don’t provide a long-term solution to the hospital-only rule. ET3 does.
The new voluntary five-year payment model allows ambulance services to divert lower-acuity medical cases and psychiatric crises to facilities that better match the person’s needs instead of defaulting to the hospital ED. Dr. Allen says ET3 is particularly good news for the mental health community because it could adequately address the ambulance-to-hospital pipeline that has been highly problematic for psychiatric emergencies, leading to unnecessary and expensive ED visits and inpatient hospitalization.
“What many people don’t realize is that when a person goes to the ED and says they’re experiencing suicidal thoughts, there is a high probability that they will be admitted to a psychiatric unit.” In September, the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) stated in a Statistical Brief that, in 2017, ED visits related to suicidal ideation or suicide attempt resulted in higher admission to the hospital or transfer to another facility than all other ED visits, 64.4% compared to 17.1%.
It isn’t just that the visits and stays themselves are costly, personally and on the system, says Dr. Allen, but that they can also cause a cascade of adverse effects such as potential job loss and the impacts of removing the person from their support system. “In most cases, the ED visit and hospitalization was unnecessary, and people remain at high risk to die by suicide after discharge,” he says.
The continued risks are stark. A study examing California ED visits found that suicide mortality within the first year after discharge was nearly 57 times higher among patients who went to the ED with deliberate self-harm—with or without suicidal ideation—and 31.4 times higher among visits related suicidal ideation but not deliberate self-harm. The transition from psychiatric hospitalization to the community is even more dire. A meta-analysis that looked at studies in Australia, Asia, Europe, and North America found a suicide death rate of 3,000 and 2,000 per 100,000 person-years in the first week and in the first month after discharge from psychiatric inpatient hospitalization, respectively.
The risks of suicide post-discharge from the ED and psychiatric hospitalization point to the need for safe transition of care from the hospital to the community, says Dr. Allen, and the importance of diverting beforehand. “For most people, that whole loop through the ED, psychiatric unit, and back into the community could be cut out, along with the additional risks and burdens.”
Not too long ago, Dr. Allen was vehemently against creating a parallel universe of mental health resources for psychiatric crises. He felt it was a matter of civil rights that the medical system could equally care for psychiatric emergencies as it does those that are medical. “That was pie in the sky thinking. It’s not going to happen.” After years of trying to push for parity, destigmatization, and reeducation, he was met with resistance. Part of the problem, he says, is that most emergency departments don’t have adequate access to mental health assets. “One reason ED physicians have been opposed to doing universal screenings for suicide is that they have no one to give the screening answers to. There is no warm handoff because mental health has never been sufficiently integrated into the medical crisis system.”
Eventually, Dr. Allen’s thoughts on developing a separate system changed, and he realized if the current crisis system won’t change to be inclusive, then another must be created. “If we accept the premise that we aren’t going to get good mental healthcare in medical settings, we must build a separate world for mental health, or else it will always be second class.”
Even in a world with two separate crisis systems, rerouting people quickly from one to the other is vital for treatment and recovery. Dr. Allen says ET3 opens up possibilities for communication between the two systems and, thereby, diversion opportunities if there is no urgent medical problem.
At present, in Colorado, a person only automatically enters the mental health crisis system if the caller contacts Colorado Crisis Services (844-493-TALK) or the National Suicide Prevention Lifeline (800-273-TALK). Calls to either number go to the same center, says Allen, even though they are handled under different contracts. Call counselors perform screenings and deescalate the majority of calls. They have also started to dispatch mobile crisis teams, which has reduced ambulance and police involvement. “We do everything we can to manage the person in-place by sending mobile crisis teams or getting the person to go to a 24-hour psychiatric walk-in clinic.”
If a caller in Colorado dials 911, there is more variability. Under state law, police and EMS can call Colorado Crisis Services to determine best next steps, but that doesn’t mean they will. More often than not, says Dr. Allen, the person will “get police and ambulance.” “There just isn’t much communication between the two systems.”
Outside of the temporary waivers during COVID-19, emergency ground ambulance services must transport to a hospital to get paid. Most often, they go to a hospital ED, but patients have no say on which. “Patients can either refuse service or go where they’re taken. That’s it.” Dr. Allen says people might assume that means EMS personnel default to the closest hospital, but that’s not always the case. If it’s between two nearby hospitals, Dr. Allen says the tiebreaker has historically been which hospital had the best coffee. “Hospitals have expended a lot of effort to make their waiting area attractive for paramedics, with coffee and donuts. They want EMS to bring patients there instead of down the road.”
Once patterns are established, they’re hard to change, and the lack of communication between the medical and mental health crisis systems hasn’t made it any easier. A common complaint among paramedics nationwide is that they spend far too many hours waiting to be released from hospital EDs. Perhaps the flexibility ET3 offers could help push for faster transitions across the board. Ideally, once 988 is up and running, mirroring 911 for mental health and suicide crises, people in psychiatric crisis won’t be transported by police car or ambulance. Still, there will continue to be intersections. How many depends on each community: how strong the partnerships are between its two crisis systems and the robustness of its mental health crisis continuum.
Under ET3, if EMS personnel find that the person is experiencing a psychiatric crisis, they can call Colorado Crisis Services, allowing them guidance on what to do next. “They might say, ‘We are with Mr. Jones who is medically stable but says he’s suicidal. He does not appear to be intoxicated or to have acute medical problems.” The crisis counselor would help them determine what mental health crisis services best align with Mr. Jones’ needs. The counselor could do a screening, send out a mobile crisis team, or have the ambulance transport the person to a crisis stabilization unit. ET3 also features a third option: CMS will pay ambulance suppliers and providers who provide in-place treatment with a qualified health care partner, either on the scene or connected using telehealth.
The concept of EMS personnel turning to an external expert isn’t unusual. In fact, EMS in Colorado can call DocLine, a lifesaving line at UCHealth at University of Colorado where Dr. Allen teaches and sees patients. The 24/7 service is available to medical providers anywhere. “If they have a patient with a problem and want to know if they should go to UCHealth to get it taken care of, they can call DocLine and get somebody medical to talk to them about where to go for the problem.” DocLine isn’t just a number to call; it’s a command center packed with large screens that display UCHealth hospital ambulance bays and helipads, real-time weather patterns, hospital ED status at each UCHealth location, and the site of every hospital in Colorado. This helps streamline the process and get people to the best place to meet their specific needs.
Though it will take some time for ET3 implementation—Colorado is still in the relationship-building phase—the hope, says Dr. Allen, is that EMS personnel will reach out to Colorado Crisis Services just as they do with DocLine, consulting with a behavioral health expert instead of a medical one. He sees this as the first step in an evolution in communication between two highly siloed systems. At present, calling Colorado Crisis Service is a free service, “but perhaps in the next iteration of ET3, it could be paid to take calls.”