Eight years ago, Shana Palmieri worked at George Washington University Hospital in Washington, DC. The hospital’s emergency room was experiencing a massive spike in behavioral health patients. “Our numbers were doubling and then tripling,” she says. Correspondingly, the length of time people stayed in the emergency department—also commonly called “the emergency room”—waiting for mental health services was also on the rise. To mitigate wait times, Palmieri, the hospital’s director of behavioral health services, spent roughly half a million dollars hiring staff. “They were highly trained clinical staff,” she says, “and they were spending the majority of their time making phone calls trying to find placements to move patients.” To address the issue, Palmieri, alongside her co-founders, developed Xferall, a platform used by hospitals, behavioral health facilities, and mobile crisis and co-responder teams to rapidly match people with the level of care they need.
Calling and faxing behavioral health facilities for placements wasn’t cost-effective for the hospital, notes Palmieri, but what she found most distressing was the adverse effect of long wait times and psychiatric boarding on patients. “People in crisis were just sitting there in a room staring at white walls for 8 to 10 hours or through an entire weekend,” she says, “making them more distressed.” The inefficiencies were harmful to both patients and staff. “Patients were understandably agitated—sometimes, they just left—and there were more and more risk events.”
Palmieri began collaborating with Nathan Read, the hospital’s chief informational officer, to drive down wait times. Read was developing a One Call center for medical transfers to resolve the same problem. “If a patient had a stroke or heart attack, the nurse would have to get on the phone and try to find a bed, which caused delays in care,” she says. Unsurprisingly, these delays resulted in worse outcomes.
Emergency medical services will typically transport people to a nearby hospital, whether a person is in a medical or behavioral health crisis. “However, that’s often not the facility with the services the patient needs,” she says. Once they stabilize the patient, the hospital will try to find a bed at a location that’s better suited to care for the person. The faster a transfer can be done, the better for the patient. “In the medical space, people say, ‘Time is tissue.’”
Like medical crises, Palmieri highlights that behavioral health emergencies also have a golden period of intervention. In fact, the duration of time between a person deciding to act and attempting suicide can be as brief as 5 to 10 minutes. “In the emergency department, we saw a great deal of decompensation of people’s condition,” she says, “because they weren’t getting the treatment they needed.” Yet, there was no counterpart to the One Call model for behavioral health transfers.
Palmieri and Read, along with two other co-founders, designed the Xferall platform to simultaneously send requests to multiple facilities. “The receiving facilities get a real-time alert,” she says. They launched the platform in Texas, where hospitals were struggling with the same challenges Palmieri faced at George Washington University Hospital. “I quickly realized this inefficiency was happening across the United States.”
She points out that the call system most hospitals use isn’t much of one at all—often, it’s a piece of paper taped at the nurse’s station with a list of nearby hospitals and phone numbers. “It’s not an automated directory updated regularly,” she says. “If a hospital closes, it gets scratched off the list.”
The process is time-consuming and cumbersome, and because staff are incredibly busy, they rarely get around to calling and faxing all hospitals on the list. “You’re looking at an hour and a half just to call 15 hospitals to find out who might have a bed,” says Palmieri. Her staff had to call and fax until a hospital discharged a patient and had space. “They had to keep calling and ask, ‘Do you have a bed now?’ and call again and ask, ‘What about now?’” In between, staff would have to get back to their patients. This inefficiency has had tragic outcomes in communities throughout the U.S. For example, on November 19, 2013, Virginia Sen. Robert Creigh Deeds’ son, Austin (“Gus”), had been in crisis observation, but the center couldn’t find him a psychiatric bed. The next day, Gus stabbed his father and died by suicide. A state investigation revealed five facilities had availability that day, but the community program crisis team hadn’t called them.
On the flip side, behavioral health facilities are often overwhelmed with calls and faxes and have insufficient tracking. “We had an inpatient psychiatric unit,” says Palmieri, “so I’d come in on Monday morning, and there would be faxes sitting on the fax machine.” She did not know if anyone had responded or whether those patients were still awaiting care.
To increase connectivity and transparency, Palmieri and her co-founders integrated a nationwide directory of all behavioral health hospitals and outpatient facilities on the Xferall platform, which geolocates to the hospital or the patient’s location. Users can toggle on criteria like level of care, age, primary diagnosis, and treatment needs. The platform then provides staff with a list of all matching facilities and can outreach them at once. “They can send it to one place or many at once,” she says.
The platform robocalls the receiving facilities’ intake line to let them know they have a transfer request and will send alerts through push notifications through the mobile Xferall app, by text, or email. “The alerts come through the portal, along with clinical data, and the entire team can see them, including the intake director, supervisor, and staff,” says Palmieri. Participating facilities also have a tab that shows all incoming requests and the status of each.
The user sending out the request can see in real-time where the patient is under review, on a waitlist, or if they’ve been clinically declined. “If it’s a Friday, and all the facilities respond that they’re at capacity and won’t have availability until Monday,” says Palmieri, “the user can expand their radius and reach out to the next batch of matching facilities.” They can keep doing so until they find a fit. For example, when a child was experiencing a psychiatric crisis in Midland, Texas, staff using the platform quickly discovered that no location within 150 miles had an opening. However, a facility in Austin did. While not ideal, the family had a choice—their son could stay in the emergency department until a bed was available on Monday or they could drive him to Austin. “His parents took him to Austin,” says Palmieri. “They didn’t want him to sit in the ED through the weekend.”
She highlights the platform allows facilities to immediately review denials, sending alerts to intake directors and supervisors every time their intake team declines a case. “That allows for real-time review,” she says. For example, a supervisor at a psychiatric hospital in a rural community saw that their staff declined a patient. They had an opening, but not for a male patient. The supervisor, understanding there were few to no options for the person within 150 miles, responded by moving beds around so that the hospital could accept him. “The ability to quickly respond was critical for getting the person timely care.”
The median time for receiving facilities to respond that a transfer is under review or on a waitlist is less than two and a half minutes. Also, hospitals can see the performance of each of their transfer partners. Using data analytics, users can also identify bottlenecks and cases especially challenging to place, whether that’s patients on dialysis or adolescents. “That helps us identify trends and continuum gaps,” says Palmieri.
While the co-founders initially developed the platform for hospitals, they soon realized it could be instrumental for mobile crisis services and co-responder teams. The latter is usually made up of two people: a traditional first responder (law enforcement, emergency medical technician, or nurse) and a behavioral health professional. So Palmieri and her colleagues built a mobile crisis feature into the platform and collaborated with multiple teams across the country. “Ultimately, the goal is that we don’t have as much volume going to the emergency department,” she says. “If we’re working with mobile crisis teams, and they can identify the level of care and make a direct referral, we can avoid those patients going to the ED or entering the criminal legal system.”
The platform, which is HIPAA compliant, allows providers throughout the behavioral health crisis continuum to contact one another. For instance, the emergency department nurse can enter and pull information on the person in crisis, and so too can the mobile crisis team and receiving behavioral health facility. “They can also send one another notes,” says Palmieri, “ensuring they’re all in communication.”
Without this connectivity within the behavioral health system, people will continue to be thrust into the highest level of care. “One reason is that providers and first responders will take the path of least resistance,” she says. Across the United States, crisis facilities often require law enforcement to stop first at the emergency department to get medical clearance. They also scaffold other hurdles like refusing intoxicated or agitated patients. Dr. Margie Balfour, chief of quality and clinical innovation at Connections Health Solutions, told #CrisisTalk in 2021 that these barriers “make jail the path of least resistance.”
Palmieri says the same is true if a provider can’t rapidly connect someone to care. “If they can’t get someone an outpatient appointment for six weeks and know their patient needs to start medication,” she says, “they’re likely to send that person to an inpatient unit.” Her goal is to make it simple for all entry points into the behavioral health system, along the entire continuum, to communicate and quickly refer and transfer patients, whether for an outpatient or follow-up appointment or crisis stabilization. “We want to make it easy for that clinician to get an appointment scheduled without calling 30 different providers to see who has availability.”