Latest / The Mental Health Evolution / Ep 49: What Happens When You Replace the Fax Machine with Shana Palmieri

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Ep 49: What Happens When You Replace the Fax Machine with Shana Palmieri · The Mental Health Evolution

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(Transcribed by TurboScribe. Go Unlimited to remove this message.) This podcast is part of the Frederick podcast
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network.
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Learn more at listenfrederick.com.
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Welcome to Mental Health Evolution, a podcast about
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what's changing in mental health and why it
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matters.
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I'm your host, Rachel Harrison, inviting you into
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honest conversations with people from all perspectives in
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the field, clinicians, tech founders, investors, insurance companies,
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and all the folks in between.
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Let's explore what's working, what's not, and what's
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next.
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Welcome back, everyone, to the Mental Health Evolution
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podcast, where we talk about how the landscape
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is rapidly evolving in the mental health industry.
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So today we are joined by Shanna Palmieri,
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who is the chief clinical officer and co
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-founder of Transferal, which if you'd like to
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Google it after our episode is spelled X
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-F-E-R-A-L-L.
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Shanna is a licensed clinical social worker who
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spent years on the front lines of behavioral
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health, including as the director of behavioral health
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services at George Washington University Hospital in Washington,
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D.C. It was there that she watched
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something that would change the direction of her
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career, patients in psychiatric crisis sitting in overwhelmed
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emergency departments for hours, sometimes days, while her
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team of highly trained clinical staff spent the
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majority of their time making phone calls and
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sending faxes to try to find them a
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placement.
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She co-founded Transferal to solve that problem
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directly.
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Transferal is a real-time patient transfer and
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care coordination platform that replaces a manual fragmented
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process with a digital system that matches patients
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in crisis to available care in minutes.
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Today we are going to talk about how
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that technology works, what she has learned about
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where technology belongs in behavioral health, and where
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she believes it should never go.
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As always, before we talk to our guest,
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we would like to bring up some relative
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articles related to our topic today.
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These articles may be helpful for listeners who
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want to learn more and dive deeper.
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All articles will be linked in the show
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notes for this episode.
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The first one here is from NPR in
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August 2025, titled Children in a Mental Health
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Crisis Can Spend Days in the ER Waiting
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for Treatment.
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And this article talks about a new study
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that found nearly 1 in 10 children on
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Medicaid who visit an emergency department during a
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mental health crisis end up stuck there for
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days waiting for psychiatric placement.
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In states like North Carolina, Florida, and Maine,
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as many as 25% of those visits
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led to children boarding in the emergency department
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for three to seven days.
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The study documents what emergency departments across the
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country have known for years that the mental
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health system is failing people at their most
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vulnerable moments, and the emergency room is often
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the worst possible place to wait for care.
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The second article here, also from NPR, is
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titled AI in the Mental Health Care Workforce
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is Met with Fear, Pushback, and Enthusiasm from
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April 2026.
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And this piece looks at how artificial intelligence
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is moving into behavioral health settings and the
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real tension it is creating on the ground.
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It covers a one-day strike by 2
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,400 Kaiser Permanente mental health providers in California,
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many of whom felt that AI driven triage
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changes were removing licensed clinical judgment from the
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process.
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This piece captures both the genuine promise and
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the very real risks of deploying technology in
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settings where getting it wrong can cost someone
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their life.
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It sets up the conversation Shanna has been
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having for years about where AI belongs and
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where it does not.
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PR Newswire is the third article.
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TransferAll expands real-time patient transfer platform in
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Southern California, this from February 2026.
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And this is TransferAll's own announcement of its
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expansion into Southern California, and it includes data
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from the platform's impact in Central and Northern
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California, where it launched in 2023.
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Healthcare facilities using the platform reported a median
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patient acceptance time of just over 60 minutes
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by the end of 2025, compared to the
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national averages of seven to eight hours or
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more for psychiatric patients awaiting placement.
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One county reported cutting their average wait time
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from more than two hours to just 17
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minutes.
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The numbers illustrate what's possible when you replace
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fax machines and phone calls with real-time
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technology.
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These three pieces tell the same story from
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different angles.
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The crisis is real, the technology exists to
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help, and the debate over how much we
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should trust technology with our most vulnerable patients
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is happening right now.
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Shanna has been living at the center of
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all three, so I am excited to begin
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this conversation.
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Thank you for being here.
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Thank you so much for having me, Rachel.
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It's a pleasure to be having this conversation
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today.
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Yeah, and I'm excited about this idea of
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wait times.
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I feel like it is a known situation
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in our field that anytime a patient goes
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to the hospital for psychiatric care, there are
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extended wait times.
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Like, that is sort of just part of
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how the landscape has looked historically.
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And even worse, I think, sometimes for kids
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and teens, because that requires a specialized placement.
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So I'd love to kind of talk through
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your journey about how you thought about the
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need and the solution to this problem.
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Absolutely.
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Now, I'll start when I was the director
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of behavioral health for this hospital.
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It was a little academic hospital, downtown, District
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of Columbia, very busy.
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We continued over the years to become more
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busy and more patient-schemed.
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So we had a team, we expanded the
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team 24-7, added staff.
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And what was quickly apparent to me was
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that as clinicians, where I really wanted us
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to be spending our time was in front
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of patients.
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If they're in crisis, that is a critical
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moment for a therapeutic crisis intervention with a
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patient and their family.
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We're trying to determine the best place for
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them to go and also to have an
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environment so that they can move quickly to
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the next place.
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And where we ended up spending the most
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of our time was administrative coordination of finding
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a It was incredibly cumbersome.
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Even when you're a large academic medical center
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and you have some of the advanced tools,
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you may have a very advanced electronic medical
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record.
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You can send documents out pretty efficiently.
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The challenge is that the system's not connected.
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So you have your system and the way
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that you do things, and then you have
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all of your partners that are part of
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different health systems.
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They have different technologies.
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They do things different way, different intake departments.
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And so because this was so fragmented, when
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I have traveled subsequently into many hospitals across
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the country, so many hospitals, they have a
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list of paper with the names of the
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hospitals on it, the fax numbers, and then
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cross them out when somebody says, Oh, I
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have a new number to send it to
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or a new email or send it this
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way.
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And then they're trying to remember what all
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of these different facilities do.
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So what's your specialty unit?
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What age range do you take?
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All these different clinical capabilities.
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And what was happening was I would have
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this team of social workers that would call
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the same group of hospitals.
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And if they were full, then you just
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wait to the next shift and then you
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call again, or you wait four hours, or
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maybe you send a fax through it and
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you call them and you say, Did you
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get the fax?
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No, it didn't come through.
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But in the meantime, we went on another
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patient.
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So now you're four hours later.
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So you can see how these administrative operational
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underlying challenges were leading to this larger system
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level issue.
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And what oftentimes I read is that the
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problem is, when I read articles on this,
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there's not enough beds.
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So maybe this is true.
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Maybe there's just never enough beds.
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And as we launched out, we found out
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there's a lot of beds available.
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There is an operational problem with how we
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efficiently link all of the services together in
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real time and find where the closest, best
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clinically matched bed is for the patient, where
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sometimes there's five, and then the family can
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have that choice.
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And instead of this process going on for
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hours, before you get a call back, and
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it's on your voicemail, and then you click
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this information, you go talk to your family.
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Now, sometimes it's in a matter of five
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minutes.
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And our median response time on the platform
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across the nation to get a response back
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about whether there's a bed available is 15
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seconds.
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So within seconds, you know, I sent this
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to 17 places.
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Six of them have a bed open right
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now.
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They're going to take a review of this
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information.
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I can go have a conversation with this
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family.
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The impact of that patient and their family's
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experience drastically changes.
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And we've done this in so many other
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markets in the world, right?
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Not in healthcare, but you know, oftentimes I'll
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say to myself, like during the time that
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we would spend going to get the fax
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sent and get somebody to call back, I'm
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like, the ER staff has ordered Uber Eats.
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We got an Uber for a patient home.
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We use all of these sort of business
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to consumer platforms to get things done.
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It uses this network approach.
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It uses this real-time digital approach, but
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we haven't transformed these technologies, these systems into
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the healthcare space where they can be really
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valuable and save lives and drastically transform someone's
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experience.
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Yeah.
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I mean, that is incredibly revolutionary for the
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way that I've experienced the mental healthcare system
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as a clinician over the last 28 years.
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Like that is a game changer.
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Yeah.
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I just, I just am amazed.
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It's pretty awesome.
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So can you walk us through how it
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works?
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If I'm a clinician in an emergency department
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who needs to find psychiatric placement for a
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patient, what happens next?
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Sure.
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So when we think about, if you're in
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the emergency department, this could also be clinicians
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in the field that may be at a
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mental health agency, a crisis team going out
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to do placement.
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So, you know, patients are in crisis in
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all sorts of settings.
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Many of them land in an emergency department,
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but any clinician who's with a patient, instead
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of that, you know, they realize their patient
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needs a different level of care and service
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than where they're at right now.
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And so they can have this app on
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their phone.
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They can have a web-based platform and
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they basically answer some basic questions about their
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patient and it will geolocate either to where
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the patient lives or their current location.
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And then it finds clinically matching facilities along
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the continuum of care.
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This might be patient may need an inpatient
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unit stay.
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They may need a crisis stabilization unit.
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They may be looking for the closest empath
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unit so that the patient has a different
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experience in terms of what their crisis assessment
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environment is like.
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They may be, they need residential substance use
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disorder, detox, PHP, IOP.
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They can come in here and select what
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they're looking for.
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And then they select maybe this patient they
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want to find who provides TMS or ECT
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or dialectical behavioral therapy.
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They want to make sure they have certain
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types of services.
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So they click these off and then it
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matches these facilities and they can start to
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just click the ones they'd like to get
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a real-time alert.
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They can put the clinical documentation in there.
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Everything's super compliant.
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It's protected.
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We have contracts and privacy, just like you
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would with an electronic medical record that you're
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using.
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And then they can submit that request.
12:23
And rather than today, where maybe you make
12:26
a phone call and get a voicemail or
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you send a fax, you get a fax
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confirmation, you're getting real-time notifications that are
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coming back.
12:34
Somebody looked at it, that it was read.
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So you get a read receipt when somebody
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looks at it.
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You can have real-time chat messaging back
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and forth with the other providers.
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Maybe they have an additional question or they
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want an additional lab work sent over.
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And so all of this is real-time
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and it's also team-based.
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So maybe the shift changes to the next
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person who's coming on and now they can
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see everywhere it was sent, all of the
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communication, what happened, what the next step was,
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and on both sides.
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So nothing's also getting lost in this process.
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Sometimes I'd be in the ER and I
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would have gotten my patient accepted and then
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my colleague comes on and they call the
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intake department and that person's like, I don't,
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did we accept that patient?
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I don't know.
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And then they start the whole process over
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again, right?
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So you have these gaps.
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Whereas when everything's really digitally documented in real
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-time, you have this back and forth until
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you get to your final acceptance.
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They can say, okay, the patient's on the
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way over.
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You get your accepting doctor, or maybe it's
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a PHP program or outpatient.
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They say, this is your appointment date.
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This is where you send the information and
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send you attachments back to give to the
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patient and the family with information.
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And then the patient moves on to that
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level of care.
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Both sides also collect an incredible amount of
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information and data on their performance, their response
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times, how often are they, do they have
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consistency and how they're accepting patients or applying
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decline criteria across staff, across your physicians, across
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your providers.
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So you start to really understand the operations
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in a different way.
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And then from a higher level, we can
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start to see truly where are the system
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gaps in geographical areas.
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So we may see this region doesn't have
14:17
the necessary medical psychiatric facilities, but three hours
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away, they have four medical psychiatric facilities that
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take patients with dialysis or intense for care
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needs.
14:27
And so you can really start to see
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even things like how far do certain patients
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have to travel?
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How far are the adolescent and children traveling?
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Because maybe there is a bed capacity for
14:36
a specific population, a specific type of patient.
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But when we say overall, well, we just
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need more beds.
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Well, what type of beds do we need?
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What type of clinical services do we need
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to really truly serve the population of behavioral
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health patients that are needed?
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And that's different by region, county.
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And so when we start to have some
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of this information, it really allows us to
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build out systems that can provide the needed
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services to patients.
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So there's different levels that I really look
15:05
at it.
15:05
One is that direct experience of the clinician
15:07
and the patient in the moment.
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And then we start to be able to
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look at more system level opportunities of where
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do we need services?
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Where do we have challenges?
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Where are the delays?
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This way, we're really engaged in this continuous
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quality improvement process from a system level, a
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hospital level, a local level.
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Right.
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How do organizations opt into this?
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You mentioned, I'm just wondering, are all hospitals
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in an area?
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Like is this something that the system goes
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and collects this data?
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Or is there a way that organizations opt
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in?
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Sure.
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So I'm going to talk about this from
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two different sides.
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One is what we refer to as the
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placement side.
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And so you have health care providers, systems,
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crisis teams, counties, they're looking to place the
15:54
patient, make a referral.
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And sometimes people are both.
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They're trying to bring patients in and they
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have patients go out, right?
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Sure.
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But on the placement side, they're joining the
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network or the platform or getting access to
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this.
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They're signing the necessary documents for, you know,
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we go through their cybersecurity and HIPAA compliance
16:12
process because they are putting patients' PHI in
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the system.
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So we take that very seriously, just like
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any other technology that is utilized to protect
16:22
this information.
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So once we do that contracting, we then
16:25
train their teams how to use the platform.
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So that's how any provider or health care
16:31
organization can join to find placement.
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On what we refer to as the intake
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side, which would be your intake department or
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anybody who's receiving referrals for behavioral health program.
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When we go into these large markets, states
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and over state lines, it is the entire
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national database of every single behavioral health facility
16:53
in the country.
16:54
And so it is PHP programs, substance use
16:58
disorder programs, mental health, dual diagnosis, what their
17:01
clinical capabilities are.
17:02
So you can search the entire United States
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to find these programs.
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And then we link them all in to
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be able to get requests.
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So whether they are participating with us or
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not, if there is a transfer or placement
17:15
user, they can send to anybody on this
17:18
network and they can send that digitally instead
17:21
of using fax, which saves significant time in
17:24
itself.
17:25
Because fax technology, no matter how you use
17:27
it, the underlying technology, you're looking at at
17:29
least 30 seconds a page for that to
17:31
go through.
17:32
It can have high failure rates.
17:34
There's a lot of challenges and the healthcare
17:36
system is still heavily dependent on fax.
17:38
So we use this to a digital transmission
17:41
of this information so that it's instantaneous, it's
17:44
real time, and it can be viewed immediately.
17:47
It also allows us to have a lot
17:49
of documentation on who's viewing the information, making
17:52
sure that it's going to the correct place.
17:54
So we're really looking at enhancing the security
17:56
of a patient's private healthcare documentation as well.
18:00
And then you have another level for transferral
18:04
intake.
18:05
And that is what we have that's our
18:07
intake suite.
18:08
And so we provide an intake platform to
18:11
intake departments that want to join and have
18:14
a contract with us.
18:15
And what we do with those is we
18:17
take all of the methods that they could
18:19
potentially get a referral.
18:21
Maybe it comes in through a fax.
18:22
Maybe it comes in through an email.
18:24
Maybe the patient walks in through their front
18:25
door or they're getting a real time request
18:29
from somebody using our platform.
18:30
It all streams into the same platform and
18:33
organizes all of these requests in one place
18:36
for their entire team.
18:37
And then we're helping lift information that's really
18:40
necessary so they don't miss anything to make
18:43
sure that the key clinical information is considered.
18:47
One of the challenges that we see in
18:50
general is you may be getting hundreds of
18:53
referrals a day.
18:54
You need to make sure your facility has
18:55
the clinical capability and the staff that is
18:58
necessary to take care of patient's needs.
19:01
Behavioral health psychiatric patients many times have comorbid
19:04
medical issues.
19:06
And facilities need to make sure that they
19:09
can take care of the entire patient, not
19:11
just the fact that they're suicidal or that
19:13
they have bipolar disorder.
19:15
So we need to take a look at
19:17
all of this.
19:18
And sometimes these clinical packets that consent over
19:21
can be 50, 100, 250 pages long.
19:25
So it's prone for missing key information if
19:27
you're trying to quickly get through the packets.
19:30
And so we're finding and lifting really key
19:33
clinical information and data to ensure that the
19:37
clinicians who, and this is a particular philosophy
19:42
of our technology company, is that the clinicians
19:45
make the decisions.
19:47
The clinicians make the final judgments.
19:50
We're providing a technology and using every advanced
19:54
underlying innovation that we can to help ensure
19:59
that nothing gets missed, that there is clinical
20:01
accuracy, and that we're lifting exactly what they
20:04
need to see to make the right decision.
20:06
But it is our fundamental belief that the
20:08
clinicians remain the person who makes those final
20:12
decisions because there's nuance to it.
20:15
There's a lot of nuance to behavioral health,
20:18
human behavior.
20:19
You have to take a look at what's
20:20
happening in your unit.
20:22
There's acuity issues.
20:23
So that's how the platform and the different
20:27
customers sort of come to be and use
20:30
the service.
20:32
That's amazing.
20:34
I'm wondering if this is ever something that
20:37
could be accessed by patients themselves.
20:41
Yeah.
20:42
It's definitely something that I would love to
20:44
see this happen at some point.
20:46
I think that it would be an incredible
20:49
space to be able to eventually move to
20:52
a consumer access.
20:54
So the challenges, and I see this all
20:56
the time, I'll have family members or friends
20:59
and they call me and they say, where
21:01
should we go?
21:03
And they're in crisis and they are trying
21:06
to find the best match and facilities and
21:12
recommendations.
21:13
And it is a complicated system for families.
21:15
So if you're not sitting there with a
21:16
clinician and sometimes you may be seeing a
21:18
therapist, but their daily job is not to
21:21
understand the network of resources.
21:23
Their job is to be a clinician.
21:25
And so when their client escalates it, that's
21:27
a challenging space too, right?
21:29
So that is something that I think would
21:32
just be incredible to be able to bring
21:34
to patients and their families to have access
21:37
to that as well.
21:39
We started with clinicians because of the challenge
21:43
of what happens right in these health systems.
21:45
But I think in the future, that's certainly
21:47
a place to end going.
21:51
I love that idea because I think it's
21:52
interesting that you started this with, do we
21:55
really have a problem with beds or is
21:58
there an access, like knowing where the beds
22:01
are kind of problem, right?
22:03
And solving for that, I think there is
22:06
potentially a similar thing when it comes to
22:10
access to care in general of that not
22:12
knowing where to go, how to find it.
22:14
And so helping people do that improves access
22:18
to care for all levels.
22:20
I love the concept behind this.
22:24
Because, you know, when I talk to a
22:26
lot of the companies, they're trying to find
22:28
access to who are the people who need
22:31
care and they have these amazing programs.
22:34
There's some fundamentally amazing work going on in
22:38
this space where there's advanced treatments, advanced opportunities.
22:42
It's through these traditional marketing methods that happened
22:47
in the past for behavioral health.
22:49
So now you're doing a search on Google
22:51
or you're searching through websites and you're trying
22:54
to find information.
22:55
And meanwhile, these programs are trying to figure
22:58
out how to do outreach, right?
22:59
Where can we help people gain awareness?
23:03
And it's a challenging and fragmented system on
23:05
many different levels.
23:07
I think in the last decade, there's been
23:10
incredible growth in the behavioral health space and
23:12
all of the levels.
23:13
Oh, yeah.
23:14
Oh, yeah.
23:15
A lot of services and programs are out
23:17
there, but there's a massive gap between awareness
23:21
of where they're at and what they do
23:23
and an easy way to find them without
23:25
sort of these traditional, just constant search methods.
23:28
And when you're in crisis, that's the last
23:29
thing anybody wants to sit down and do
23:31
is a, you know, eight to twelve hour
23:34
day as a family member calling and researching.
23:37
And that's not your specialty in life.
23:39
But it's very challenging.
23:41
So certainly I think there are some huge
23:43
opportunities.
23:44
I love that idea.
23:46
And I just want to highlight that you
23:48
are I you said this, but HIPAA compliant
23:51
information is protected.
23:53
That's not always a given in our in
23:56
our field right now.
23:58
So I just want to highlight that.
24:00
And is this something that is part of
24:03
your technology here?
24:05
It is.
24:06
So when we look at artificial intelligence, I
24:10
think with any new innovative technology, there's a
24:14
space where we have to be very mindful
24:16
and ethical with our use and really taking
24:19
a look at what the best use cases
24:21
are.
24:22
I always feel like there is a very
24:24
positive use case we don't want to miss
24:26
out on because it can really add to
24:29
the treatment of our patients.
24:31
So I'll give some examples of where I
24:33
think that it is really impactful.
24:36
So one of the ways and this is
24:37
one of the things that I was mentioning
24:38
was really lifting critical information to make sure
24:41
that nothing is missed.
24:43
So clinical accuracy is incredibly important.
24:46
And I've seen in my career, you have
24:48
a patient come into the emergency department or
24:51
you're trying to accept a patient and you
24:53
just have so many records.
24:55
And somewhere in a note somewhere, there's something
24:57
critical that if you miss could be detrimental
25:00
to your patient's outcome.
25:02
And sometimes it could be fatal.
25:06
You know, a patient has an allergy.
25:07
They can't take a certain type of medication.
25:10
There are many challenges that we experience in
25:13
the health system like that today.
25:14
And this technology absolutely helps with pulling critical
25:19
information to the top and organizing information in
25:22
a way that allows clinicians to have at
25:26
their fingertips the information they need to make
25:28
critical and oftentimes life-saving decisions for patients.
25:32
So in that way, when we're looking at
25:34
how are decisions made when we have lots
25:38
of clinical data that need to be considered,
25:41
we do use artificial intelligence to help pull
25:44
this information so that we can really take
25:46
a look at it.
25:47
And when we really are thinking about artificial
25:49
intelligence, what we're really looking at here is
25:52
an incredible ability to look at pattern recognition
25:55
and to pull information.
25:56
And I think it's important to really sort
25:58
of understand what it is that it's being
26:01
used for, because when we look at the
26:03
treatment of behavioral health patients, we need clinicians,
26:06
we need human beings to be at the
26:08
center of that treatment.
26:09
That's our best intervention point that we have
26:14
is being present as a human being with
26:18
another person to help move them and help
26:21
formulate a plan and an intervention to help
26:25
that person move forward clinically and with their
26:28
treatment.
26:28
When we look at the operations of how
26:30
the entire behavioral health system works and is
26:32
connected, I think there's incredible opportunity there to
26:36
enact resources, look at patterns, look at where
26:42
are we missing things?
26:43
Are there areas where we could make operational
26:45
improvements?
26:46
So I look at the use of artificial
26:49
intelligence.
26:50
In our particular space, we're using this as
26:53
an operational tool and we're using it to
26:56
lift clinical information to enhance the accuracy and
26:59
to give clinicians what they need in order
27:02
to make decisions and to be at the
27:05
forefront and still that final decision maker and
27:08
still that clinician doing that clinical work.
27:10
And we also use it to reduce administrative
27:12
burden on highly trained clinicians.
27:15
Nobody wants to retype a field three different
27:18
times in three different systems, right?
27:20
That like over-documentation, connecting technology systems together,
27:25
making sure that data flows on the back
27:27
end.
27:28
This all allows us to do our jobs
27:30
better and it removes clinicians from having to
27:32
do administrative work and gets them back in
27:34
front of their patients.
27:36
So I think that operational use case for
27:39
artificial intelligence is really helpful.
27:42
And I think right now that's where, you
27:46
know, I would say personally a lot of
27:47
my energy is focused because I think there's
27:49
an incredible operational, there's incredible challenges in the
27:53
space and opportunities so that we can really
27:56
connect the system together and allow patients to
27:59
get where they need to go very quickly.
28:01
And we address this issue where we could
28:04
be missing key clinical information.
28:07
I think there's another area where the pattern
28:11
recognition, when we look at your diagnosis of
28:15
a patient, your clinical formulation of a patient,
28:18
your treatment options of a patient, the way
28:20
that I look at this, and this is
28:22
not something that my company is involved in
28:25
at all, we are completely operational and working
28:29
on efficiency and connecting patients.
28:31
But I think it's a very interesting space
28:33
to have a conversation about because I think
28:35
this is where much more of the fear
28:37
exists.
28:38
And I think that when you look at
28:42
diagnostic categories today, there's system, you know, there's
28:45
symptom clusters in the DSM, and we're basing
28:48
our treatment interventions off of those clusters that
28:52
have been developed in the DSM.
28:53
And so there's traditional challenges that behavioral health
28:57
space has in comparison to where medical diagnosis
29:01
has come.
29:02
Like we can't, I can't do a blood
29:03
test and tell somebody that they have, what
29:05
type of psychosis that they have.
29:08
And one of the things that I think
29:10
artificial intelligence can help us with because it
29:14
can engage in this really powerful pattern recognition
29:18
is not diagnosing our patients, but ensuring that
29:21
clinicians are asking the right questions, and that
29:23
we don't miss a question to ask.
29:25
Because if I have a patient who comes
29:27
into my emergency room with psychotic symptoms, I
29:30
have to do an entire differential about where
29:33
those symptoms came from.
29:34
And I want to make sure that this
29:35
isn't delirium.
29:36
Did they have a UTI?
29:38
Are they using substances?
29:40
Maybe they, some patients in rare cases, have
29:43
brain tumors.
29:43
There's this entire differential.
29:45
And so where I feel like in the
29:47
future artificial intelligence can help us is making
29:51
sure that clinicians are asking the right questions
29:53
and not missing anything for their clinical diagnostic
29:56
formulation.
29:56
It gets us to a better treatment plan.