It started with an open letter in 2015 from Sheree Lowe, vice-president of behavioral health for the California Hospital Association:
“California, like the nation, is struggling to ensure individuals with a suspected/potential mental illness are able to receive a timely psychiatric evaluation and access to an appropriate level of treatment, if needed. The California Hospital Association (CHA) represents over 400 hospitals. In 2011, these hospitals received over 1.1 million individuals in their emergency departments (EDs) in need of some level of behavioral health intervention. An analysis of emergency department utilization data between 2006 and 2011 verified that the overall use of EDs for behavioral health visits increased 47% during this 5-year time period and the trend data indicate this continues to increase each year. The vast majority of individuals arriving at a community medical/surgical hospital ED with a behavioral health need do not have a physical health condition that requires an emergency level of care intervention. This holds true for psychiatric emergency medical conditions as well. Unfortunately, however, there are often no alternative behavioral treatment settings available on a 24/7 basis. This forces hospital emergency departments, including those without behavioral health clinicians, to become the only available resource in many communities. The increasing dependence on medical/surgical hospital EDs to provide behavioral evaluation and treatment is not appropriate, not safe, and not an efficient use of dwindling community emergency resources [emphasis ours]. This includes not only hospitals, but emergency transportation providers and law enforcement. More importantly, it impacts the patient, the patient’s family, other patients and their families, and of course the hospital staff.”
Lowe’s letter detailed the problems California faces because it lacks 24/7 mental health emergency services. This forces people into a choke point of emergency departments (EDs) during the involuntary care commitment (IVC) process. The letter was meant to coordinate and support the goal of a 2014 effort to rewrite decades-old IVC laws to facilitate better consumer service and minimize the deficiencies of the crisis system. In one year, the lack of timely access led over 1 million people to seek interventions in EDs. She pointed out the burden this places on citizens, their families, and the hospitals themselves. Five years later, Lowe provides her insights into the accessibility of crisis services now and her hopes for the future.
“Today in California, about 6,000 people a day, with a behavioral health condition, are languishing in hospital EDs. When law enforcement detains and transports someone, the only option they have is EDs or jails, which is usually not the best clinical fit for most people’s crisis,” says Lowe. She contrasted her frustrations with the current system with what happened when her cousin recently had a traumatic motor vehicle accident. His medical emergency needs required him to be airlifted to a trauma hospital that had the appropriate tools and resources to match his needs. His insurance, his location, or the acuity of his trauma were not barriers to finding and receiving immediate access to established standards of care for his injuries. Meanwhile, his friend, who was also in the accident, did not experience the same level of trauma and was transported to a closer ED that fit her clinical needs. “Why can’t we make our behavioral health crisis system function in that way?” Lowe asked.
Lowe reports several barriers to overcoming this challenge to improve crisis responses. She describes the infrequent presence of no wrong door crisis receiving units in California. There are some crisis stabilization units in limited areas of the state, but many have extensive exclusionary criteria, making it hard for those in crisis to access focused crisis care services versus going to the hospital ED. This creates the common crisis conundrum where many areas of the state force law enforcement, often the default mental health crisis first responder, to take the person to jail or the ED.
There are also significant funding challenges and silos that create vast differences in financial obligation for people in crisis, notes Lowe. For example, county-based Medicaid Mental Health Plans (MHPs) are in charge of the entire IVC system for all Californians, even though they are only funded for the care and services provided to the Medicaid beneficiaries. For individuals covered by commercial insurance plans, there is no obligation to fund and/or develop crisis services.
What makes cohesion even more challenging, says Lowe, is tension between the community social rehabilitation recovery model of care versus the medical model hospitals operate in. Neither system appears to function in a unified way with a foundation or understanding of trust and support for each model, yet both are needed to treat the whole person as they move through their recovery journey. “Community providers provide care using a recovery based rehab model, and hospitals treat using a recovery medical model. We become involved when the rehab model fails, yet we aren’t always considered part of the recovery delivery system. Partnership and trust must strengthen as we work toward healthier communities and better care.”
Finally, a lack of data and outcome measurements further exacerbates the chasm. “Nobody wants to track or report more data for a variety of reasons, but that’s a narrative we have to change.” It is difficult to evaluate how 58 different California counties are implementing the IVC laws, how managing crises in different ways truly affects costs, ED utilization, diversion from inpatient and/or involuntary stays or justice system involvement. The inability to measure the efficacy of these disparate approaches affects whether we can meet the needs of the community in the most efficient manner possible or gather accurate insight into the scale of problems in addition to determining the need for new resources.
Lowe’s goal is to make a difference. She has her ideas of ways California could approach improvements, including the need to unify and have consistency statewide and simple pathways for people in behavioral health crises to access care. Just as we do for individuals in need of different levels of medical care. This requires dedicated 24/7 crisis services, in every community, specifically for psychiatric emergencies that can be accessed by all with little or no need to involve law enforcement. This would also include consistent interpretations of IVC laws across the 58 counties. She recommends updating the State’s 50-year-old involuntary commitment laws to align with the current behavioral health care delivery system and clarify the role law enforcement and hospital emergency departments should play in that process.
A next important step would be to develop a greater trust between the opposing systems of the medical versus social rehab models. Lowe has seen a few programs in California that merge strengths of both approaches to achieve a Crisis Now outcome, aligning practices to SAMHSA’s National Guidelines for Behavioral Health Crisis Care. These models need to be the standard and available in all communities throughout the state.
Lowe contemplated the creation of a novel state agency—one that doesn’t have a financial stake or bias in the system and is charged with tracking data, supporting system redesign, and evaluating outcomes for crisis care rather than 58 different delivery systems independently trying to solve this enormous challenge facing all of California’s communities. Her powerfully worded open letter in 2015, championing the importance of not using EDs to manage mental health crises, was the impetus for this article. When it comes to offering viable alternatives for individuals in acute mental health or substance use crisis, not much has changed. Some of the barriers facing California occur commonly across the US: no dedicated crisis services, siloed funding, limited reimbursement of crisis care by commercial insurers, lack of data and outcomes to drive quality improvement, and tensions between recovery and medical models. She sees hope in tackling these problems and points out one more final reason why we all have to take this on…
“People often call the population we serve marginalized. I think they are disenfranchised. If we want to look at the explosion of people in jail, prison, or who are homeless, it’s that they’re disenfranchised, and it’s not just going to go away without the right big picture approach.”
Dr. Chuck Browning is the Chief Medical Officer for RI International and leads its Fusion Model efforts to integrate peer-empowered care and the direct access of hospital EDs and law enforcement.