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Innovating Emergency Psychiatry: Meeting Behavioral Health Demand Head-On · Becker's Healthcare Behavioral Health

• 0:00
  Hello, everyone. This is Jacob Emerson with the
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  Becker's Health Care podcast. Thrilled today to be
• 0:04
  joined for an exciting conversation around the pressing
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  issues shaping the future of health care. And
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  to do that, I am joined by doctor
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  Scott Zeller, who's the vice president of psychiatry
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  at Vituity and an assistant clinical professor of
• 0:17
  psychiatry at the University of California Riverside School
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  of Medicine. So in today's episode, we're going
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  to be exploring a critical and increasingly visible
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  challenge, the growing demand for behavioral health services
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  within hospital emergency departments.
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  With an estimated twelve to fifteen percent of
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  ED visits now tied to psychiatric needs, hospitals
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  are under intense pressure to deliver timely and
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  effective care. Doctor Zeller is here with us
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  to share his valuable insights from both the
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  clinical and leadership perspective. He'll also discuss the
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  systemic barriers hospitals are facing, and he'll also
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  dive into the innovative care models emerging to
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  improve patient outcomes and operational efficiency. So without
• 0:57
  further ado, doctor Zeller, thank you so much
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  for taking the time to be with us
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  here on the podcast.
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  Absolutely. It's a pleasure. Looking forward to our
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  conversation.
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  Likewise, Scott. And before we dive into everything
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  we wanna talk with you about, can you
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  tell us a little bit more about yourself,
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  your background in health care, and what it
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  is that you're doing today at Vituity?
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  Well, you did a nice job introducing my
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  main titles,
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  but, I've been an emergency
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  psychiatrist for approaching forty years now. For more
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  than twenty years, I led
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  psychiatric emergency services for Alameda County, California, which
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  is Berkeley, Oakland, and some other cities.
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  And I've really been passionate about improving
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  emergency psychiatry. A lot of my work and
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  research has been in helping people who are
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  experiencing
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  agitation or aggression.
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  And I've also been working on innovative models
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  to, assist people who are in an emergency
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  mental health crisis,
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  including, the being the inventor of what's known
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  as the EMPATH model, emergency psychiatric assessment treatment
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  and healing units.
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  Fantastic. Well, really glad to have you with
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  us on the podcast today, Scott.
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  Let's talk about something I mentioned when we
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  when we first started off today, about the
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  estimated twelve to fifteen percent of ED visits
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  now being behavioral health related. So in this
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  environment, what are some of the challenges that
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  you're seeing hospitals face in terms of delivering
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  psychiatric services? And, ultimately, what are the systemic
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  issues that are contributing to this?
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  So it it's been an amazing thing in
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  that the, the last ten, fifteen, twenty years,
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  we've seen an enormous increase in the number
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  of people coming to hospital emergency departments
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  for a behavioral health emergency.
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  And it actually between 02/2006
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  and 2015,
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  there's a great study that showed that the
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  number of people coming to ERs
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  for being suicidal, for example, went up over
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  four hundred percent.
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  So there's just this enormous number, like you
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  said, one in one in seven
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  of patients that are coming to emergency departments
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  are there for a behavioral
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  reason, and,
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  that's created some some difficulties and some log
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  jams in those hospital emergency departments.
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  Traditionally,
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  their role was, let's do a medical screening
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  exam, make sure that these people are otherwise
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  medically okay, and then let's move them on
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  to a psychiatric hospital.
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  That might have worked when it was one
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  in every twenty five of your patients. But
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  when it's one in every seven,
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  then you start to run into some problems
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  that the math doesn't quite work.
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  So if you had the idea that everybody
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  who is coming in, your role was to
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  hold them until you could get them into
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  a psychiatric hospital, when you're suddenly inundated by
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  these patients,
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  you don't have, you know, a lot of
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  places for them to go. There's been no
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  real increase in in hospital inpatient psychiatric beds
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  in in recent years. Lot of decrease, actually.
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  So, like I said, the numbers don't quite
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  go together.
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  And and the real problem is then that
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  you create something called boarding in the emergency
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  departments
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  where you have a large number of patients
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  who are pretty much sitting there taking up
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  available beds, available
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  space, waiting for nothing more than transfer to
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  an inpatient facility. I mean, we see boarding
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  in a lot of different
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  medical conditions, but it's really, really a a
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  big issue with the behavioral health patients.
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  And so the the issue around that is
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  is that
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  according to EMTALA,
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  that psychiatric emergencies are emergency medical conditions.
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  So psychiatry emergencies are, unfortunately, the only emergency
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  medical conditions where historically
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  our approach has been, let's find them an
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  inpatient bed. So to compare, if you came
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  to the ER really short of breath, unable
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  to breathe, you're having an asthma attack, if
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  we treated you the same way that we
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  treat psychiatric emergency patients, we'd say, oh, I'm
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  so sorry about you suffering this inability to
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  breathe. Why don't you come with me? We've
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  got a stretcher in a back hallway we're
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  going to put you on, and you're gonna
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  just sit tight there until we can find
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  you an asthma hospital. And it'll only be
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  a day or two. So so keep breathing,
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  and we'll be back to you in a
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  few hours.
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  And that sounds kinda ridiculous, but it's exactly
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  what we do with people who are suffering
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  from a behavioral health emergency.
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  And the answer, surprise, surprise, just like it
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  would be with that asthma patient
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  is to
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  evaluate somebody and initiate treatment right away. And
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  when we do that, we really have game
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  changer results.
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  Understood. And and just to reiterate,
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  a number that you mentioned there, Scott, that
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  one in seven patients are facing these
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  issues. This is a major challenge for hospitals
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  all over the country. So I think the
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  natural follow-up question here is, in this realm,
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  what are some of the new models or
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  approaches that you're seeing emerge
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  to to both improve the patient experience but
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  also hospital efficiency? What what are you seeing
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  on the ground in terms of examples and
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  outcomes from around the country?
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  So I think one one of the main
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  things that I could just mention is actually
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  seeing these folks as,
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  you know, people who deserve,
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  immediate assessment and treatment
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  is the real big difference instead of saying,
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  okay, we're just gonna hold them in the
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  treatment and evaluations and interventions are gonna take
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  place somewhere else on an inpatient psychiatric facility.
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  Instead, thinking of them like we think of
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  every other emergency patient and that these are
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  people who are suffering,
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  they need our help, and let's go ahead
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  and start providing it. So
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  that's very possible to do in the emergency
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  department, and we see a lot of models
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  that have improved situations around the country, which
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  really involve getting a psychiatric prescribing provider to
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  quickly evaluate that patient, for example. So maybe
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  that's through telemedicine, like telepsychiatry.
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  Maybe that's through having certain hours of days
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  with a, a psychiatric provider station in the
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  emergency department. So those can actually improve things
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  and do have the opportunity
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  to provide treatment, and we will see,
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  increased opportunity for these folks to be
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  charged rather than being held for admission and
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  really get their needs met quickly. So that's
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  a really good thing. However,
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  the one major,
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  drawback about trying to do all this in
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  the emergency department is
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  the ER is not a great place to
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  be if you are having a psychiatric emergency.
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  It's kind of very busy. It's noisy. There's
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  scary things going around. People are running. There's
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  a lot of people in pain.
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  It's difficult to get somebody's attention. And all
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  these kind of different things are well known
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  in studies to actually make psychiatric emergencies,
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  that makes those symptoms worse.
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  So
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  what we've really seen, one of the greatest
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  models that has come out in recent years
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  is
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  why don't we get our emergency behavioral health
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  patients out of the ER altogether
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  into a unit that's very close to the
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  ER, adjacent, perhaps even within the ER footprint,
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  or worst case scenario, elsewhere on that hospital
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  campus, but it's still very close by where
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  it's really designed and tailored to working with
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  people
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  experiencing a behavioral health emergency.
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  So that it's calmer, it's more
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  spacious and and therapeutic and soothing where a
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  patient who you know, a lot of our
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  patients having psych emergencies
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  need to pace around or need to be
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  moving to help themselves decompress and reduce anxiety.
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  So what if we gave them space to
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  do that? In regular ER, somebody be saying,
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  hey. Get back in that bed or I'm
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  calling security. Or they'd be forced because of
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  different regulations to have them with a one
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  to one sitter at all times. What if
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  they were in a space where they could
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  move around
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  and sit and do what they want, maybe
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  engage in a board game, not have to
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  ask permission for anything, but be able to
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  get themselves
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  a beverage or a snack. And and and
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  they really be able to see,
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  staff as their allies
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  rather than their adversaries.
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  And that's the the foundation for the model
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  that's known as empath, which is really to
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  create this healing environment where people can go,
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  where they get their emergency psychiatric assessment,
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  then treatment right away, then healing happens in
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  that that therapeutic environment. That's the EMPATH acronym.
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  And so it's it's been this wonderful, wonderful
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  thing that hospitals are starting to realize. Hey.
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  You know what? These these behavioral emergency patients
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  are our patients too. And just like people
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  coming in with with chest pain or or
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  or shortness of breath or or car accidents
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  or what have you, we can help these
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  folks. And we actually find that if the
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  hospitals do create an EMPATH unit and real
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  quickly, EMPATH units are are not it's not
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  some kind of special brand name or,
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  something that you have to buy and bring
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  in. EMPATH is just a name for a,
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  a hospital
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  psychiatric emergency ER, if you will.
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  Just like you would have a labor and
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  delivery unit, you can have an empath unit.
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  Nobody needs to give you permission. You can
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  just bring one on yourself. And by moving
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  these patients quickly out of the emergency department,
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  just like you would move somebody who came
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  in to the ED who is pregnant, you
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  can move them quickly to labor and delivery.
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  You can move psych patients quickly to empath
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  where they get rapidly evaluated,
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  assessed, if treatment is indicated, meds are indicated,
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  those get started right away, and then we
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  start to have really, really wonderful
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  outcomes. So out of those same patients, even
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  including
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  involuntarily
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  detained psychiatric emergency patients,
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  the same patients that if they were in
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  the ER
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  moved to EMPATH, we thought that a hundred
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  percent of them needed to go to an
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  inpatient bed,
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  seventy five percent or more get better and
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  can go home from the EMPATH unit.
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  Similarly, that same population in the emergency department
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  would, on average, about twenty percent of them
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  would end up in physical restraints
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  during their stay in the emergency department in
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  EMPATH units. That number is far lower than
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  one percent. In fact, it's more like one
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  or two out of every one thousand. So
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  same population,
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  hundred and fifty to two hundred out of
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  every thousand in restraints or one to two
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  out of every one thousand. What a difference
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  that makes, and that leads to those much,
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  much better outcomes. And then we know there's
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  a lot of concern about workplace violence in
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  these days.
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  A lot of workplace violence might be involving
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  aggressive agitated individuals.
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  What we know is that two thirds of
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  patient
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  to staff injuries
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  occur during that time when they're trying to
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  put somebody into physical restraints.
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  So if you avoid
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  the need to have that course of intervention
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  altogether
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  and you have a,
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  you know, calm, you know, happy patient who's
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  working together with you, the chances of you
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  having a workplace violence episode or having to
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  put them in restraints goes way, way, way
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  down. So it's it's truly like a win,
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  win, win, win across the board. We get
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  those folks out of the ED, which opens
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  up patients in the emergency department for nonpsychiatric
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  patients. So even if you've never had a
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  behavioral emergency in your life, you're gonna benefit
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  if there's more space available in the ERs.
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  It helps reduce
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  wait times in the ER waiting rooms left
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  without being seen. You don't need sitters in
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  the ER because when they move to EMPATH,
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  that's considered
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  the appropriate level of care without need for
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  sitters.
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  And then once they get there, you're gonna
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  be able to help these folks in less
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  than twenty four hours. The great majority of
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  them get better and are able to go
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  home, and that's gonna save the whole system,
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  the costs of many inpatient admissions.
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  And when you do have that twenty or
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  twenty five percent of folks who'd still need
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  inpatient,
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  they end up having more beds to be
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  able to go to because you're not just
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  funneling everybody through. And then for those who
• 12:34
  might say, wait. If they're going to Empath,
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  then maybe they're not staying long enough. They're
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  just gonna come right back to the ER
• 12:41
  again. We actually see just the opposite. You
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  there's great studies in major peer reviewed,
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  emergency medicine journals that show that
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  the recidivists,
• 12:51
  the number of people that sometimes get called
• 12:53
  frequent flyers, if you will,
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  the number of people
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  returning to the emergency department
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  from,
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  after EMPATH
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  compared to previous where they were going to
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  inpatient,
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  the number that return within thirty days is
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  usually twenty five to fifty percent less than
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  they were in the past. And why is
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  that? Well, maybe it's because
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  the patients who go to EMPATH
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  are sixty to eighty percent more likely to
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  show up for their first
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  outpatient appointment
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  than the way they were when they were
• 13:22
  getting discharged from inpatient units. So
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  long, long, long, long little explanation there, but,
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  really, it's a win win win win win
• 13:30
  win win for everybody.
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  And every bit of care there is reimbursed
• 13:34
  by Medicaid, Medicare, private insurance.
• 13:38
  You have just great outcomes, patient satisfaction,
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  super high.
• 13:42
  Really hoping that, maybe some people listening today
• 13:45
  might think, gee. Maybe EMPATH's the solution for
• 13:48
  us as well.
• 13:49
  Certainly. So hospitals should be treating these patients
• 13:52
  as if they were treating anybody else, but
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  those treatments should be happening in in settings
• 13:56
  that are not as chaotic as the ED.
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  When we see new care models gain traction,
• 14:02
  though, Scott, we know the hospitals often encounter
• 14:05
  operational, financial,
• 14:07
  regulatory hurdles during these implementations.
• 14:10
  So from the leadership perspective, what are some
• 14:13
  strategies or best practices you think health systems
• 14:16
  can can use to navigate these challenges successfully?
• 14:20
  Yeah. It's a great question. And and one
• 14:22
  of the, you know, just about everywhere that
• 14:25
  we've seen try to create EMPATH units, and
• 14:28
  there's about 50 operating in The United States
• 14:31
  right now, and we know there's gonna be
• 14:33
  more than a hundred in The US by
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  2027.
• 14:36
  And they're in six or seven,
• 14:39
  other countries,
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  Canada, Mexico,
• 14:42
  Scotland,
• 14:43
  Australia,
• 14:45
  United Arab Emirates, all these places are opening
• 14:48
  up empath units, which is really, really wonderful.
• 14:50
  But one of the things that that comes
• 14:52
  into play, like, to your question, is that
• 14:56
  anytime time you try to do something new,
• 14:58
  it's going to come with some logistical issues.
• 15:01
  And especially if you're in a state that
• 15:03
  hasn't had EMPATH before,
• 15:05
  you know, a lot of times there, you'll
• 15:06
  you'll run into regulators or surveyors or
• 15:10
  or state,
• 15:12
  reimbursement officials who say, well, we don't know
• 15:14
  what this is, so we don't like it,
• 15:16
  so you can't do it. And that's obviously
• 15:18
  a problem. As I described before, this is
• 15:21
  such a win win win win win across
• 15:23
  the board. It seems,
• 15:25
  amazing that anybody would not want it to
• 15:27
  happen, and it's like a money saver while
• 15:29
  giving better care. So it seems kind of
• 15:32
  silly that anybody would be opposed to it,
• 15:34
  but there you go. Sometimes folks are just,
• 15:36
  here's the way we do things, and, we
• 15:38
  are we're not interested in doing it any
• 15:40
  differently. So what I would say at at
• 15:42
  individual hospitals,
• 15:44
  what we've seen that always leads to success
• 15:48
  is having
• 15:49
  an identified
• 15:51
  project manager or or the identified person who's
• 15:53
  running
• 15:54
  the effort to change the way that you
• 15:57
  do things with emergency psych patients. Now maybe
• 15:59
  you don't have an ER that's busy enough
• 16:01
  to justify
• 16:03
  a, an empath unit. We'd say, like, if
• 16:05
  you're having less than four behavioral health patients
• 16:08
  a day, you probably that you don't justify
• 16:10
  an empath unit. But if you're having more
• 16:12
  than that, which would be something along the
• 16:15
  lines of 1,500
• 16:16
  to 2,000 patients a year, the empath makes
• 16:19
  a lot of sense. But if you're going
• 16:21
  to do it, you need to have somebody
• 16:22
  that you're identifying
• 16:24
  as that project leader, the project manager who
• 16:26
  understands it, who gets it, if you will,
• 16:29
  and really wants to drive the process
• 16:31
  and is
• 16:33
  ready to, you know, take on all those
• 16:35
  challenges, those hurdles, and and know that the
• 16:38
  pot of gold at the end of the
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  rainbow is really gonna be something.
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  But if you try to go about it
• 16:43
  saying, like, oh, maybe we should do this.
• 16:45
  Well, here's a committee of 15 people who
• 16:48
  are gonna talk about doing it. It's gonna
• 16:50
  be a lot harder to make it happen
• 16:52
  for the exact reasons you described. There's gonna
• 16:54
  be challenges. There's gonna be,
• 16:56
  you know, hurdles
• 16:58
  to overcome.
• 16:59
  And if you got somebody who really is
• 17:01
  a strong leader and identified
• 17:04
  as a thought leader in your system who
• 17:06
  can get people to say, yeah. Let's make
• 17:08
  this happen. It's gonna work, and you're gonna
• 17:10
  have great outcomes.
• 17:12
  Yeah. And your point is well heard, Scott,
• 17:14
  that that sometimes hospitals are operating in in
• 17:17
  rigid structures that can make it difficult to
• 17:19
  address some of these problems.
• 17:20
  I think in that vein, if you were
• 17:22
  to look ahead, how do you see the
• 17:23
  health care system evolving to better meet the
• 17:26
  needs of psychiatric patients
• 17:28
  in the ED more broadly?
• 17:30
  And what's the role that innovation is going
• 17:32
  to play in terms of shaping the future
• 17:34
  of crisis
• 17:35
  stabilization?
• 17:37
  Great question. And the answer to that is
• 17:40
  is that hospitals,
• 17:41
  first of all, need to realize
• 17:43
  that the behavioral health patients are not going
• 17:46
  away. They're gonna be coming in. Right now,
• 17:48
  if there are one in seven, one in
• 17:50
  eight of your patients,
• 17:52
  you know, if you had one in every
• 17:54
  seven of your patients was coming in with
• 17:56
  chest pain, you wouldn't be looking at ways
• 17:58
  to prevent chest pain patients from coming to
• 18:00
  your hospital.
• 18:01
  But what we do see is people
• 18:04
  hearing about,
• 18:06
  programs being built elsewhere in the community,
• 18:09
  other ideas going on outside of the hospital
• 18:12
  that are sometimes come with the promise, oh,
• 18:14
  if only we spend money and build this
• 18:17
  new program,
• 18:18
  nobody's going to have to come to the
• 18:20
  hospital ER with a behavioral emergency again.
• 18:23
  And sometimes that sounds like music to the
• 18:26
  ears of people who work in the ER
• 18:28
  or administrators,
• 18:30
  because they think, okay. Well, that's just around
• 18:31
  the corner. Well, unfortunately,
• 18:33
  it that's never the case. And you can
• 18:35
  have wonderful, wonderful crisis programs and nothing against
• 18:38
  those programs because they do yeoman's work and
• 18:41
  they do fantastic things.
• 18:42
  However,
• 18:43
  there's just still gonna be a a huge
• 18:46
  percentage of patients, no matter how good your
• 18:48
  crisis system is, that are still gonna come
• 18:50
  to the emergency department. A few years ago,
• 18:53
  I published an article on the 10 different
• 18:55
  kinds of patients that are gonna come to
• 18:58
  ERs no matter what you do externally.
• 19:00
  And some of them are are really kind
• 19:03
  of obvious.
• 19:04
  Like, what happens if you are a behavioral
• 19:06
  emergency patient who took an overdose in an
• 19:08
  attempt to kill yourself? Are we gonna take
• 19:10
  you to the drop in counseling center, or
• 19:12
  are we gonna take you to the ER?
• 19:15
  You know, the ER is gonna be the
• 19:16
  one who's gonna be able to save your
• 19:17
  life. So that's a direct, you know, to
• 19:20
  the ER, obviously. But also patients who maybe,
• 19:24
  have other comorbid medical conditions,
• 19:26
  who might be acutely intoxicated or in withdrawal,
• 19:29
  who
• 19:30
  are agitated, aggressive, violent, have history of of
• 19:33
  some scary things. Those are all gonna be
• 19:35
  told that those other programs you need to
• 19:37
  go to the hospital ER. And then, again,
• 19:40
  because of EMTALA, the hospital ER can't say
• 19:42
  no. You should go somewhere else. They're gonna
• 19:44
  have to work with everybody and try to
• 19:46
  stabilize them. So anytime we hear about these
• 19:48
  other programs, it's great. We need all those
• 19:51
  programs. We want them. We love them. However,
• 19:54
  the buck always stops at the emergency department.
• 19:56
  And if we're looking at one in every
• 19:58
  seven patients coming there, is there for a
• 20:00
  behavioral emergency reason? We need to be prepared,
• 20:03
  and we need to have a way that
• 20:05
  we can work with these folks because there
• 20:07
  needs to be a recognition, these are our
• 20:09
  patients too. And we can have great outcomes,
• 20:12
  we can do good things with them as
• 20:14
  long as we kind of focus the same
• 20:15
  way we would if all of a sudden
• 20:17
  there was all kinds of different medical conditions
• 20:20
  that we start seeing, we would adjust to
• 20:21
  that. Same thing with the behavioral emergency patients.
• 20:24
  When we do that, we're gonna have really,
• 20:26
  really great outcomes and actually, ironically,
• 20:29
  reduce the number of long term patients coming
• 20:31
  because we do such a great job. They're
• 20:33
  far less likely to come back. We're turning
• 20:36
  our emergency patients into outpatients,
• 20:38
  and that leads to a win win again
• 20:40
  for everyone.
• 20:42
  Lots of win win wins today, Scott. It
• 20:44
  sounds like.
• 20:46
  Before we go, anything that we're missing that
• 20:48
  we haven't covered? We've got a lot of
• 20:50
  hospital leaders listening in from all over the
• 20:52
  country. Your final thoughts for them?
• 20:56
  The final thought would be is that,
• 20:58
  the EMPath units do not have to be
• 21:01
  a very expensive undertaking.
• 21:04
  What we found is that a lot of
• 21:05
  hospitals
• 21:06
  might have some underutilized
• 21:08
  space
• 21:10
  around their, their facility.
• 21:12
  And the neat thing about an EMPATH unit
• 21:14
  is, and I didn't describe this before, is
• 21:16
  that instead of being
• 21:19
  a unit with a lot of individual rooms,
• 21:21
  an Empath unit is a big open space
• 21:24
  where you have recliner chairs instead of beds,
• 21:28
  where people are free to move about. There's
• 21:30
  a gentle direct observation from an open nursing
• 21:33
  station. Everybody's kind of there in this enclosed
• 21:36
  but open and comfortable environment where there's natural
• 21:39
  light and high ceilings
• 21:41
  and no, evidence of coercion rather than this
• 21:44
  is a mellow place you can hang out.
• 21:45
  You can go sit and play a game
• 21:47
  of dominoes with another staff member and and
• 21:49
  with some other patients and or you can
• 21:51
  get yourself something to eat or drink, relax,
• 21:54
  wait for the doctor to start your meds.
• 21:56
  You can do all these great things.
• 21:58
  And because it's a big open room, you
• 22:01
  don't have to build a lot of specialized
• 22:03
  parts to that. You don't really need to
• 22:06
  worry about building a lot of walls or
• 22:07
  specialized units or things that come out of
• 22:10
  the walls or what have you. Instead, if
• 22:12
  you have any underutilized open spaces, we've
• 22:15
  seen hospitals use an old conference room, an
• 22:18
  old room where they did the the cardiac
• 22:21
  rehab. We even saw a hospital that that
• 22:23
  took,
• 22:24
  an outdated chapel and made it into an
• 22:26
  empath unit. Any wide open space can be
• 22:28
  do it, can be done to, to make
• 22:30
  an empath unit.
• 22:32
  And when you do that, the the remodeling
• 22:34
  costs
• 22:35
  are surprisingly
• 22:37
  low and affordable.
• 22:38
  So you're talking about creating this wonderful new
• 22:40
  program that solves a lot of problems for
• 22:42
  you in a very, very low,
• 22:45
  you know, cost to actually take it from
• 22:48
  idea to fruition.
• 22:50
  And, you know, it's it's what I spend
• 22:52
  all my time these days on. I've got
• 22:54
  a wonderful team of colleagues
• 22:56
  that we go to help hospitals all around
• 22:58
  the country
• 22:59
  to create these. And so any one of
• 23:01
  your listeners who might wanna reach out and
• 23:03
  talk to me, and I can give you
• 23:04
  some recommendations on how you can have an
• 23:06
  empath unit too.
• 23:08
  Wonderful. Well, doctor Zeller, thank you so much
• 23:10
  for taking the time to sit down with
• 23:12
  us and for sharing your insights with our
• 23:13
  listeners. We truly appreciate it. Well, thank you.
• 23:16
  It was a great interview. Really appreciate it.
• 23:18
  I'd also like to thank our podcast sponsor,
• 23:21
  Vituity. You can tune into more podcasts from
• 23:23
  Becker's Healthcare by visiting our podcast page at
• 23:26
  beckershospitalreview.com.