Behavioral health ED visits on the rise

Even though overall emergency department use in Massachusetts declined in 2014 – visits associated with behavioral health conditions rose sharply, according to preliminary findings on Emergency Department Utilization Trends from the Health Policy Commission (HPC) 2015 Cost Trends Report.

The data shows that emergency department (ED) use associated with behavioral health conditions (mental health and substance use disorders) increased 24 percent state-wide between 2010-2014.

Matthew Kitsos, a HPC spokesman said via email that the rise has coincided with growth in the opioid epidemic. Lack of timely treatment also drives use of the ED for behavioral health conditions and HPC is investing in pilot programs aimed at accelerating adoption of evidence-based standards of care, and building behavioral health requirements into its provider certification programs.

He also said integrating behavioral health capacities into the health care system is critical and the HPC is working – both through investments and certification standards – to increase the ability of providers in both primary and acute care settings to be equipped to screen for and triage behavioral health disorders.

Emily Mohr, Ph.D., licensed clinical psychologist and the Massachusetts Psychological Association public education coordinator said further analysis of this developing data is needed, but speculated that increased opiate and substance use may be driving many people into medical crisis and pushing them into EDs, where Narcan can be administered to prevent the effects of overdose.

While the medication may prevent death from overdose, “Unfortunately, there isn’t any real treatment that happens, and they go back into the world” and continue the same behavior, Mohr said.

“If we are going to decrease emergency department visits, actual treatment is needed there,” Mohr said. “Emergency medicine providers are not trained to assess behavioral health situations.”

Mohr, who works for an integrated behavioral health clinic that is embedded in a medical center, said increased training and better integration of medical and behavioral health is needed, such as by having a full team of behavioral health professionals in EDs so there can be appropriate triage right then and there. “They ought to be there – clearly, these numbers demonstrate that,” she said.

Aside from substance use, Mohr also highlighted the need for greater funding for mental health and outpatient treatment in general. “It’s important for people to get treatment early on so that it doesn’t develop into a crisis situation, and that people do have knowledge of where to turn,” Mohr said.

The HPC report found that more than 50 percent of long-stay (eight or more hours in the ED) visits for pediatric patients were related to behavioral health.

Charmain F. Jackman, Ph.D., licensed clinical/forensic psychologist with an expertise in children, adolescents and families, and a member of the MPA Board of Directors and Public Education Committee, said she hopes these statistics spur more conversation about the behavioral health needs of young people.

She said services for mental health in general are underfunded, but it is even more profound among children and adolescents.

“In my role as a school-based clinician, we have to rely on mental health services in the community, and there often aren’t a lot of services there for students, or there’s a long waiting list,” Jackman said.

Without services and treatment, children can end up in urgent situations and in EDs. “Without prevention services we’re operating in a way that we’re always responding to a crisis,” Jackman said. Because students spend so much of their time in the classroom, schools should be able to better access services and offer education for youth, with a focus on prevention, emotional support and improving resiliency and stress management skills, she said.

“Many youth have very limited coping skills for anything that’s stressful,” Jackman said. “They don’t have common problem-solving skills, so they may look for the quick fix. I see an increase in self-injury and other ways to cope.”

In the report, one area that saw a dramatic increase was the South Coast (with increases in Fall River and New Bedford of 53 and 48 percent, respectively).

However, that increase should lessen because of the recently opened Southcoast Behavioral Health, a 120-bed inpatient behavioral health hospital in nearby Dartmouth and a partnership between Southcoast Health and Acadia Healthcare.

The facility started accepting patients Aug. 31, opening 2 of 5 units (48 beds) and admitting almost 500 patients as of January. All five units should be open by April.

Southcoast Health spokesman Peter Cohenno said individuals who suffer acute mental health problems still need to go initially to one of Southcoast’s three EDs. “However, once the patient is stabilized, he/she can be transferred to Southcoast Behavioral Health where specialized care is available,” Cohenno said.

Prior to Southcoast Behavioral Health, there was very often nowhere in the region to send a mental health patient so they were forced to board in the ED until a bed opened up elsewhere, he said.

At any time, at least 25 percent of the EDs clinical care spaces were occupied by behavioral health patients awaiting placement.