Emergency Department Boarding of Psychiatric Patients in Oregon

Transcription

1 College of Public Health and Human Sciences Emergency Department Boarding of Psychiatric Patients in Oregon Jangho Yoon, PhD, Jeff Luck, PhD April 25, 2017

2 Scope Quantify the extent of psychiatric emergency department (ED) boarding in Oregon Identify contributors of ED boarding Identify potential solutions

3 Methods Analyses of quantitative databases Interviews with mental health experts and key stakeholders

4 Analysis of Quantitative Data Sources

5 Topics Extent of psychiatric ED boarding in Oregon Recent trend in psychiatric ED boarding in Oregon Determinants of psychiatric ED boarding in Oregon

6 Data Sources Hospital discharge (564,151 ED visits) Oregon Association of Hospital and Health System (OAHHS) performed data linkage. Linked data set contained 690,245 unique hospital ED visits (290,181 unique patients), 10/2014 9/2015 Emergency Department Information Exchange (EDIE) (539,923 ED visits) Medicaid (391,479 ED visits)

7 Definitions ED boarding ED stay longer than 6 hours ED stay longer than 24 hours Psychiatric visit ICD-9-CM and CPT codes Severe vs. non-severe Psychiatric ED boarding Boarded psychiatric ED visit (6 hours and 24 hours)

8 Rate of Psychiatric ED Boarding in Oregon (1) N = 690,245 unique ED visits, 10/2014 9/ hour definition 6-hour definition All psychiatric, 85.4% 14.1% 15% 85.4% All psychiatric, 15% 12.5% 0.51% Non-psychiatric Psychiatric, not boarded Psychiatric, boarded 2.13% (29,763 visits) Non-psychiatric Psychiatric, not boarded Psychiatric, boarded

9 Rate of Psychiatric ED Boarding in Oregon (2) Boarding incidence: Psychiatric vs. non-psychiatric 14.6% 3.5% 3.9% 0.8% 24-hour definition 6-hour definition Psychiatric visits (n = 100,809) Non-psychiatric visits (n = 589,436)

10 Rate of Psychiatric ED Boarding in Oregon (3) Boarding incidence: Severe vs. non-severe psychiatric condition 24.4% 9.1% 12.8% 2.5% 24-hour definition 6-hour definition Severe psychiatric visits (n = 15,394) Non-severe psychiatric visits (n = 85,415)

11 Rate of Psychiatric ED Boarding in Oregon (4) Different cutoffs for boarding definition: 6 24 hours 14.6% % boarded for all psychiatric visits 11.4% 9.8% 8.8% 8.1% 7.6% 7.1% 6.7% 6.3% 6.0% 5.6% 5.3% 5.0% 4.7% 4.4% 4.1% 3.8% 3.6% 3.5% > 6 > 7 > 8 > 9 > 10 > 11 > 12 > 13 > 14 > 15 > 16 > 17 > 18 > 19 > 20 > 21 > 22 > 23 > 24 ED hours

12 Average Boarding Time in Hours Boarding time definitions 6 hour: Total ED hours 6 24 hour: Total ED hours hour definition 6-hour definition All boarded ED visits Psychiatric: All Psychiatric: Severe Psychiatric: Non-severe Non-psychiatric

13 Trend in Psychiatric ED Boarding in Oregon (1) 50,000 48, % 49, % 8.0% 7.0% 46, % 6.0% 44,000 43, % 43, % 4.0% 42, % 40, % 1.0% 38,000 Oct, 2014 Nov Dec Jan, 2015 Feb Mar Apr May Jun Jul Aug Sep 0.0% All ED visits % boarded ED visits

14 Trend in Psychiatric ED Boarding in Oregon (2) Psychiatric vs. non-psychiatric 70% 62.4% 60% 50% 40% 30% 37.6% 28.4% 52.6% 47.4% 35.2% 20% 10% 9.2% 12.2% 0% Oct, 2014 Nov Dec Jan, 2015 Feb Mar Apr May Jun Jul Aug Sep Psychiatric: All Psychiatric: Severe Psychiatric: Non-severe Non-psychiatric

15 Determinants of Psychiatric ED Boarding (1) Person-level factors Substance abuse Male gender Severity of psychiatric condition Psychiatric ED boarding Rural residence Medicaid enrolled

16 Determinants of Psychiatric ED Boarding (2) Person-level factors (cont d) Severe psychiatric visits more likely to be boarded by 16 percentage points. 10 hours longer boarding time for severe psychiatric visits. Medicaid enrollment reduced boarding time by 2.7 hours.

17 Determinants of Psychiatric ED Boarding (3) System-level factors Mental health resources Psychiatric ED visits Psychiatric ED boarding Measures of county-level mental health resources Community mental health: Ratio of patients served by ACTs to persons with SMI Inpatient: Ratio of psychiatric inpatients to persons with SMI

18 Determinants of Psychiatric ED Boarding (4) System-level factors (cont d) More mental health resources reduce psychiatric ED visits. 1% increase in Change in psychiatric ED visits Intensive community mental health resources 12% decrease Psychiatric inpatient resources 9% decrease Psychiatric conditions increase ED boarding Compared to non-psychiatric visits, psychiatric visits: Led to two-fold increase in ED boarding probability Increased boarding time by 5 more hours

19 Stakeholder Perspective on Psychiatric ED Boarding in Oregon

20 OSU interviewed knowledgeable stakeholders about emergency department boarding of psychiatric patients 31 stakeholders, from all regions of Oregon, were interviewed during January & February 2016 about: Causes and impacts of psychiatric boarding Potential solutions Stakeholders represented a variety of organizations: Hospitals and Emergency Departments Administrators and clinicians Community mental health programs County mental health departments Advocacy organizations Coordinated Care Organizations OHA staff 19

21 Causes of Psychiatric Boarding: Preventing ED Visits Limited outpatient treatment capacity Long wait times to see behavioral health providers Insufficient capacity in community-based treatment programs, e.g, ACT or intensive case management, in some counties Limited availability of stable housing for persons with mental illness Limited or underutilized alternatives to EDs Insufficient capacity of crisis response centers or mobile teams in some counties Limited number of psychiatric emergency centers Unity center opened recently in Portland Limited awareness of alternatives among providers or law enforcement 20

22 Causes of Psychiatric Boarding: Post-ED Care Challenges in discharging ED patient to community settings Limited availability of slots in community residential or treatment settings Especially on weekends or for persons with comorbidities Limited training or time for ED staff to identify appropriate community destinations Inadequate capacity in more intensive treatment settings OSH is backlogged with.370 population Sub-acute facilities (non-hospital units with 24/7 treatment) are in short supply and not reimbursed by all payers Detoxification treatment capacity is very limited, especially in rural areas 21

23 Impacts of Psychiatric Boarding ED boarding of psychiatric patients is very stressful for patients and their caregivers ED is not a clinically appropriate setting to treat mental illness Boarding is also stressful for ED staff and disrupts ED operations 22

24 Potential Solutions to Psychiatric Boarding Expand capacity of specific services, including: Community treatment programs Sub-acute facilities Programs to assist persons discharged from inpatient care or OSH Supportive services, including housing and substance abuse treatment Manage more.370 patients in community settings to reduce backlog at OSH Monitor effectiveness of new psychiatric emergency centers Improve the ED environment for psychiatric patients e.g., peer support, dedicated space Explore opportunities to improve reimbursement for nonhospital services 23

25 Conclusions from Stakeholder Interviews Perspectives of Oregon stakeholders were consistent with statistical analyses and published research literature Causes of ED boarding are multifaceted Solutions should focus on expanding capacity of programs that prevent psychiatric ED visits and facilities that provide appropriate care after ED discharge Adding more inpatient psychiatric beds is not the best solution If the Affordable Care Act were repealed, reductions in OHP enrollment would likely exacerbate the psychiatric boarding problem 24