In June of 2012, as members of the Milford
Regional Medical Center’s Patient/Family Advisory Council (PFAC), we were
searching for a direction to go. Dr.
Jeff Hopkins, Chief of the Emergency Department, gave a presentation to us
about the care of behavioral health patients in the Emergency Department and
how the volume impacted the E. R. The patients who came to the E.R. needed
follow-up care but the resources for staff to refer them to were very limited.
With the deinstitutionalization (of mentally ill patients), the use of antipsychotic
drugs can help to control the behavior of this patient population but this
often results in homelessness and the revolving door syndrome. Patients with drug
addiction and/or mental health issues and subsequent problems need active
intervention and follow-up care. They
are a growing number of E.R. patients, often seen on an emergent basis. These people are devastated; they do not know
where to turn, so they seek out care and support in the E. R. and often arrive
in a crisis state. The staff, not being trained in psychiatric care, aim to
keep the patients safe, maintain their medicine regime and actively seek out
appropriate behavioral health care support…essentially custodial supportive
care while in the E.R. The result was long-term stays in the E.R. (sometimes
this meant many hours or even days), which was troubling. It was especially
difficult to place patients who’d been violent, children and those patients who
had complex medical problems in addition to their behavioral issues as well as
the difficulty of placement of behavioral health patients on the weekends.
As the PFAC Co-Chair at the time, I met with
Dr. Hopkins to discuss how the PFAC could realistically have an impact on this
issue. We discussed ways to educate the
community about the Behavioral Health Care crisis, and to identify ways to
short-circuit the crisis step by connecting the E.R. patients to community
services in a more timely fashion. This was our initial approach to define the
role of the PFAC Subcommittee within the hospital: to define “better care”. We on
the PFAC had a couple of meetings to discuss how to accomplish this effort. By
September 2012, we started meeting on a monthly basis.
I became the head of the Behavioral Health
Subcommittee of the PFAC at that time because I believed the PFAC, through
collaboration with other healthcare providers, could make a difference in
behavioral health care in the E.R. I
felt this issue impacts us all because it impacts health care in general as
well as care in the E.R. If ten of 30
beds are occupied with behavioral health patients, especially if occupied for
extended periods of time, this impacts bed availability for all other patients.
The goal of the PFAC Subcommittee was to find ways to improve care with better
resources in the community and thus ultimately alleviate the impact on the E.R.
Assuming responsibility as Chairperson, my
role through all of this was to get this challenging endeavor on track. Monthly
meetings were and continue to be held. To develop a more comprehensive approach
to this issue, we reached out to others who dealt with this patient care
population. For example, we invited representatives from Case Management, Social
Service, Nursing and Riverside Counseling Services to join the subcommittee in
an effort to improve care of the behavioral health patient. It took a real
strong collaborative approach and the PFAC was part of all of those
discussions. As the PFAC Subcommittee chair, I worked with the E.R. behavioral
health team to incorporate everyone’s input, obtain feedback from others and
evaluated how it was all working. I,
along with other members of the PFAC Subcommittee, presented the PFAC and ED
Behavioral Health Program at the Health Care for All PFAC State Conference at
Holy Cross, the Massachusetts Coalition for the Prevention of Medical Errors,
the Juvenile Advocacy Group (JAG) Community Breakfast and at a webinar hosted
by Health Care for All.
We formed a diverse group with Dr. Hopkins,
Chief of the Emergency Department, community caregivers, a child psychiatrist,
Riverside Emergency Services, Nursing, Case Management, Social Service and a
family member who dealt first hand with the issues of trying to find care for
her son in crisis, etc
We reached out to the E.R. staff for their
input and perspective on Behavioral Health Care in the E.R., asking for their
suggestions on how to improve care of the behavioral health patient while in
the E.R. The nurses developed a list of very helpful suggestions to enhance the
care of the behavioral health patient while under their care. Some creative but
simple suggested improvements included: a predictable schedule, showers,
attention to proper nutrition, an opportunity to take a walk, exercise, music, etc.,
since some of these patients were in the E.R. for days. This effort showed the
staff we were willing to listen and we valued their input.
As a result of this collaborative effort
between the PFAC, Emergency Department, Case Management and Community Benefits,
we received a grant from the EOHHS (Executive Office of Health and Human
Services). This grant enabled us to provide an educational program for the E.R.
nurses interested in Behavioral Health and to provide initial funding for
Behavioral Health nursing positions. The first group of behavioral health
nurses became mentors for their colleagues in the E. R. This initiative was very well received by the
nursing staff.
An integrated team was developed comprising Case
Management, ED front line staff, Riverside, and other mental health care
workers. Patients are evaluated during daily rounds in the E.R. Therefore they
all know where each patient is in their care management and what follow-up
resources could be identified. At one time, for those patients on behavioral
watch or at risk of suicide, we had security guards watching over them. A
program was developed to train people as Patient Safety Advisors. These people
are specifically trained to interact with the behavioral health care patient in
the E. R. while they waited for individualized plans of care.
Next we looked into the community for
resources available to provide timely care and counseling to the behavioral
health patient population. Our thinking was if we could provide opportunity for
timely care and support we could short circuit the need for crisis intervention
in the E.R. at 3 am. Information was
presented to our PFAC Behavioral Health Subcommittee about the Interface
Referral Service of the Massachusetts School of Professional Psychology (MSPP).
This service provides information about services available in and around the
community and guidance in how to navigate the mental health system. I, as well as others on the team, reached out
and spoke with other communities who had successfully utilized this service.
This was the first time this organization would be working in a hospital broad
based outreach. In February of 2013, we signed a contract with Interface. In addition
to making the information about this service available in our E.R, we notified
(via letter) the schools, pediatricians’ offices, Counseling Services, Youth
Groups in town, Library’s Youth Department, etc., all in an effort to make the
public aware of this referral service.
This was one more step in our effort to make Behavioral Health Care better
and available to our community when needed.
We’re trying to meet the
patients’ needs for medication, personal needs, etc., with active intervention,
not just custodial care in a hospital setting with a
broad-based community outreach.
Stay tuned for Part 2. In the meantime, read a story about other
innovations by Patient/Family Advisory Councils at Milford and Beth Israel
Deaconess Medical Center.
