Emergency departments (EDs) across the country are struggling to meet the growing demand for behavioral healthcare. At least one in eight ED visits now involves a mental health or substance abuse issue.
The difficulty in caring for patients in behavioral health crisis has been exacerbated by a growing shortage of both psychiatrists and inpatient mental health facilities. Compounding these challenges is the rapidly evolving regulatory landscape that hospitals must operate in.
Risk of EMTALA Violations
EMTALA is a federal law requiring hospital EDs to medically screen every patient who seeks emergency care and to stabilize or transfer those with medical emergencies, regardless of health insurance status or ability to pay. The law also considers psychiatric emergencies to be medical emergencies.
Recently, AnMed in South Carolina was ordered to pay $1.3 million for failing to attempt to stabilize psychiatric patients prior to transfer or boarding. The hospital boarded psychiatric patients for up to 38 days until space became available at the state mental hospital rather than notifying an on-call psychiatrist or treating at an inpatient unit.
In another example, the Central Maine Medical Center (CMMC) was found to have violated EMTALA after ED staff advised police and EMTs not to bring psychiatric patients there. In an email to the sheriff's office, CMC stated that as a trauma center they cannot provide proper care for mental health-related conditions, requesting that this patient population be transported to another hospital.
CMMC was also found to have violated EMTALA by insufficiently monitoring the third-party mental health agency with which it contracted to provide crisis evaluations. It is the hospital's obligation to ensure that those crisis evaluations are performed and documented in the patient's hospital record.
This resulted in CMMC’s Medicare Certification being terminated pending a plan of corrections, which was filed and has been accepted.
The Joint Commission Considers Expanding ED Suicide Screening
A Joint Commission technical advisory panel is considering whether all patients presenting to the ED should undergo suicide screening. Current standards require screening for behavioral health patients only.
Studies show that the majority of people who die by suicide visit the ED in the last six months of their lives. For this reason, many health systems have moved toward universal screening of patients.
However, expanding screening could also exacerbate existing supply and demand issues. Emergency physicians are concerned, as there are not enough behavioral health resources as is. The requirement to screen all patients, even those without behavioral health complaints, could infringe on the ability to care for those with acute needs.
CMS Begins Reporting on ED LOS
Centers for Medicare and Medicaid Services (CMS) has begun collecting ED length-of-stay (LOS) data for psychiatric/mental health patients. Data capture on Hospital Outpatient Quality Reporting Measure OP-18c started in October 2017. CMS will publicly report the initial results in late summer 2018.
Pressure Increases on Physicians to Improve Transitions of Care
The Merit-Based Incentive Payment System (MIPS) now governs reimbursement of physicians and groups. By 2020, 9 percent of MIPS Medicare payments will be at risk based on quality reporting and performance.
In 2017 and 2018, CMS introduced four new MIPS measures focused on transitions of care in psychiatry. They have also proposed removal of some psychiatric measures related to substance abuse and restraints. You can read more about the latest psychiatry measure set here.
New Quality Measures Introduced for Inpatient Behavioral Health
The Inpatient Psychiatric Facility Quality Reporting (IPFQR) is a CMS quality program that monitors the performance of psychiatric hospitals and inpatient behavioral health units.
IPFQR introduced new measures for 2017–18 focused on improving transitions of care and preventing readmissions. Notable examples include:
- Timely transmission of transition records to both patients and primary care providers
- Follow-up after hospitalization for mental illness
- 30-day all-cause readmissions rate
The last measure is especially notable, because some behavioral health disorders carry very high readmission rates. For example, 22.7 percent of patients admitted with a psychotic disorder like schizophrenia return to the hospital within 30 days of discharge. Only congestive heart failure has a higher readmission rate.
Transforming Healthcare to Improve Lives
New models of care are addressing the psychiatric burden on our nation’s EDs and changing the approach to assessing and treating patients experiencing a behavioral health emergency. As a result, hospitals have a significant opportunity to transform the healthcare experience of one of the most complex and underserved patient populations.
To learn more about how Vituity is leading the transformation of behavioral healthcare delivery through proven, cost-effective methods, please visit https://www.vituity.com/services/acute-psychiatry.