Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at .
Dr. Scott Zeller, past president of the American Association for Emergency Psychiatry and vice president of acute psychiatry at Vituity, has long been troubled by disparities in emergency medicine. “When you come to the emergency room with an asthma attack, staff start you on treatment right away,” he said, adding that emergency medical care aims to treat the person and discharge them or admit them to the hospital.
That’s not the case with mental health emergencies. People can spend hours languishing, without treatment, in the emergency room waiting for an inpatient psychiatric bed, a practice called psychiatric boarding. Lawsuits across the nation have increased attention on the issue.
As with medical emergencies, people in mental health and substance use emergencies respond best when treatment is initiated quickly. “The sooner someone is stabilized, the faster they can be discharged to a less restrictive level of care,” said Zeller.
During his nearly three-decade tenure as chief of psychiatric emergency services at Alameda Health System in Alameda County, California, the number of patients coming to the emergency room for mental health or substance use issues continued to rise. He said, by 2013, “one in eight patients coming in was there for behavioral health reasons.”
Zeller points out that the emergency room isn’t the right fit for most people in a behavioral health crisis. “We know the ER environment itself feels punitive, coercive and claustrophobic,” he said, adding that people’s symptoms often get worse. Even so, the twin mental health and substance use crises in the United States have meant more people are showing up in the emergency room than ever before, and if there’s nowhere else to go, that won’t change.
Communities throughout the U.S. are increasingly aware of the pitfalls and high costs of emergency room visits for people in mental health distress. The pandemic and 988 — the nationwide number for mental health and substance use crises — have sparked increased focus and funding on building interconnected community-based crisis systems, including contact centers people can call or text, 24-hour mobile crisis services, and 23-hour crisis receiving and stabilization programs.
“What’s been overlooked is what happens to those who will continue coming into the ER, people who are in psychosis, have comorbidities, or a serious danger to themselves or others,” said Zeller, adding that many community-based programs can’t, or won’t, take involuntary patients. “Highly acute mental health patients are often the most underserved.”
He was convinced he and his colleagues could change outcomes if the hospital system had a homelike, therapeutic program for people who’d otherwise be held in an emergency room waiting to go to an inpatient unit. “We could ensure they’d see a psychiatric professional and start on treatment as quickly as possible,” he said.
The problem was he didn’t think anyone would believe him.
Zeller, who was in charge of psychiatric emergency services for Alameda County, started collecting data. All the county’s major general hospital emergency rooms were already sending their involuntary psychiatric hold adults to Alameda Health System for evaluation. “We did a 30-day study, looking at the patients the five hospitals sent us who they’d otherwise have to admit to an inpatient hospital,” he said.
At the time, the average psychiatric boarding wait time in California was over 10 hours. “That’s after the emergency room has done a medical evaluation,” said Zeller.
The study illustrated that Alameda County’s average hold time of 1 hour and 48 minutes was far less. The stabilization rate among the involuntary hold population was 75.2 percent, with most able to return home. The study laid the groundwork for EmPATH crisis stabilization units, a 23-hour psychiatric emergency medicine model Zeller developed but has no plans to brand. “It’s not branded or licensed so that anyone can do them,” he said.
The acronym EmPATH stands for “emergency psychiatry assessment, treatment and healing” and represents the model’s empathetic, trauma-informed approach. “It’s the emergency path to mental health care and the order of how emergency care should happen — assess, treat, and heal,” said Zeller. The model includes evaluation and treatment for both mental health and substance use disorders.
The units are typically near the emergency room, either in the hospital or on the hospital campus. Because they’re within the hospital system, EmPATH units must follow EMTALA, a federal law requiring that the public has access to emergency services regardless of their ability to pay. “The law doesn’t apply to community-based programs,” said Zeller, adding that non-hospital programs can turn people away or choose people they deem less complicated or expensive to treat.
“If a person is in an acute crisis, has medical comorbidities, is going through acute intoxication or withdrawal, is on involuntary hold or perceived as violent, community-based facilities can divert them,” he said, “but the emergency room has to see everyone who comes to their door.”
He believes the law fosters parity, where psychiatric emergencies are treated as medical emergencies, just like heart attacks and car accidents. Even so, the emergency room isn’t a therapeutic environment for a person in a mental health emergency. “That’s why we created a separate, distinct program nearby that has an open environment,” said Zeller, adding that the approach is collaborative, not adversarial or punitive. A psychiatric provider sees patients on the unit and rapidly initiates treatment.
The approach has resulted in less seclusion and/or restraint than in a standard emergency room. “It’s one or two out of every 1,000 patients,” he said. A study of emergency room seclusion or restraint outcomes, published in 2014, found either to occur in 14% of psychiatric emergency patients, with those rated severely disruptive by a clinician at higher risk. Other risks included if the person came to the emergency room in restraints, didn’t initiate the referral, was experiencing mania or psychosis or arrived between 7 pm and 12:59 am.
In designing EmPATH, Zeller developed a home-like therapeutic setting with recliners instead of beds where movement isn’t restricted. “You can get yourself something to eat or drink, he said. “You never have to beg a staff member for anything.” There also aren’t security guards or sitters. Many of the units have outdoor spaces called healing gardens.
Because communities can tailor EmPATH to fit their needs, size varies. “They might be as small as 6 recliners or as large as 36,” said Zeller. Most have the capacity to serve 12 people at a time.
Many programs also do post-discharge follow-ups to check in, ensuring the person has their medication and reminding them of upcoming appointments. If the person is struggling, EmPATH partners with community-based providers to connect the person to care. “They can work with a mobile crisis team and let them know, ‘We were able to get the person back home but they’re having a difficult time today — would you mind stopping by and checking on them?’”
Funding, says Zeller, comes from grants, philanthropic organizations, and public and private insurance reimbursement. Thirty-two states, including California, Iowa, Minnesota, Pennsylvania, South Carolina and Virginia, have or are creating EmPATH units, with California and South Carolina investing tens of millions of dollars, $20 million and $45.5 million, to expand the hospital-based crisis stabilization units.
There’s a financial incentive for hospitals to include EmPATH units. The University of Iowa Hospitals and Clinics found that having one resulted in $861,065 of estimated annual revenue by treating patients who would have otherwise left, such as leaving without being seen or against medical advice. The unit diverted people in rural areas experiencing suicidal ideation from inpatient hospitalization and lowered psychiatric boarding times.
Zeller’s aim with EmPATH is to turn emergency patients into outpatient ones, something a colleague once said that’s stuck with him ever since. “That should always be our rubric — how can we help someone back into their home, their community, so they don’t get into an emergency again?”
