Sign reading "Emergency" with an arrow to the tall hospital buildings behind it.

With EDs increasingly becoming the primary treatment center for many patients with mental health concerns, hospitals need to consider alternative workforce strategies and models of care to more quickly assess and treat psychiatric patients in the ED and refer them to the appropriate level of care quickly and efficiently.

If you have been closely following the news and data, you know our nation’s emergency rooms need reinforcements. 

Hospital emergency departments (EDs) across the country have reported a steady increase in patients presenting with behavioral health issues. Unfortunately, EDs are not designed or staffed to provide behavioral health patients with the care that they need. In fact, many EDs do not have access to an on-call psychiatrist for psychiatric emergencies. Research published by the Mayo Clinic in April 2022 found that of the more than 2,300 U.S. hospitals surveyed, 54% reported having no psychiatrist on staff or available for medical ED and inpatient consultation.

As a result, patients seeking behavioral health care in hospitals can languish for hours or days waiting for specialized care or bed placement. This leads to boarding, which is the practice of holding admitted patients in the ED when there are no inpatient beds available. Boarding is especially common among behavioral health patients due to the lack of psychiatric providers and inpatient services.

Boarding has become such a significant concern that nearly three dozen of the country’s leading provider groups recently urged the White House to address the issue. The nine-page letter depicted a bleak picture and declared the rise in boarding “its own public health emergency” for adults and children

Compounding the problem, hospitals are facing unprecedented staffing shortages and clinician burnout in the wake of the COVID-19 pandemic. Hospital providers, staff and resources have been stretched to a breaking point as patients’ behavioral health needs continue to grow.

Easing ED gridlock with telepsychiatry and virtual collaborative care 

The fact is that ED boarding is costly. A landmark 2012 Wake Forest University Health Sciences study found that psychiatric patients tend to wait 3.2 times longer in the ED than non-psychiatric patients, preventing 2.2-bed turnovers (or additional patients seen), which costs the ED $2,264 per patient when considering direct and opportunity losses. This, in turn, can lead to poor patient experiences, poor care, and poor outcomes for psychiatric and medical patients. Traditional care delivery models, operational workflows, and ways of thinking will not overcome these complex and multi-faceted challenges. 

As an industry pioneer, employer of choice for behavioral health clinicians, and the nation’s leading virtual psychiatry and therapy practice, Array Behavioral Care is uniquely positioned to ease the boarding strain in our hospitals through telepsychiatry-based solutions. More than 20 years ago, our executive chief medical officer conducted one of the nation’s first involuntary commitments via telepsychiatry for a patient in need at a rural hospital. Since then, we’ve partnered with hundreds of hospitals and health systems, community healthcare organizations and payers of all sizes to expand access to care and improve outcomes for underserved individuals, facilities, and communities.

Empowering clinicians

Array’s clinicians work with hospitals and health systems to implement innovative, physician-led programs grounded in evidence-based tools and protocols. It all starts with telepsychiatry which offers ready access to skilled, reliable, and experienced behavioral health clinicians ranging from adult and child and adolescent psychiatrists and psychiatric nurse practitioners (NPs) to licensed social workers and therapists. These behavioral health specialists provide guidance and support to onsite attending ED physicians with evaluation, disposition decisions and treatment for psychiatric patients.

Telepsychiatry can help reduce psychiatric boarding in the ED in 3 key ways:

  1. Expert assessment to ensure patients are being dispositioned to the most appropriate, least restrictive level of care
  2. Initiate stabilizing treatment when patients are awaiting an inpatient bed
  3. Reassess patients daily to evaluate whether those awaiting inpatient placement could be better treated at a lower level of care

With the virtual team approach, the treatment teams that are already commonly used in collaborative care programs in community-based settings across the country are paired with virtual licensed mental health specialists. This structure can be applied to acute psychiatric care in hospitals to increase access, quality and efficiency in behavioral health care, benefiting both ED providers and the patients they serve. 

In practice, psychiatrists and psychiatric NPs function more as expert consultants, while therapists, social workers and other levels of behavioral health specialists can also be layered into the virtual behavioral health care team. Psychiatrists are available virtually to perform psychiatric assessments or mental status exams, serve as a consultant to the attending ED physicians or prescribe medication directly as appropriate depending on the needs and preferences of the hospital, and make risk determination, capacity to discharge and disposition recommendations. This expedites treatment and improves the quality of care for individuals with mental health concerns and frees up ED resources for more acute medical presentations.

Hospitals leveraging this model ensure the highest and best use of all clinicians’ time. Physicians and hospital staff onsite can rely on these virtual behavioral health care teams can help triage and assess individuals presenting with mental health concerns and make decisions regarding admission, discharge and referral for these patients. 

The more behavioral health team members who are staffed virtually, the more significant the reduction in the operational, logistical and financial burdens that the onsite provision of those services would require. Virtual behavioral health care teams can also help support strained and overextended onsite staff in the ED and help curb clinician burnout, which costs the U.S. an estimated $4.6 billion annually. 

Transformation across the continuum of care

Telepsychiatry is the lifeline our hospitals need to reduce ED gridlock. The boarding emergency is another troubling outcome of our country’s ongoing mental health crisis. Policy changes are still needed at the state and national levels to close access gaps, allow clinicians to be reimbursed for telehealth services at the same rates as in-person services and further enable widespread adoption of telehealth across the continuum of care. 

At Array, we are intently aware that reliable patient access to behavioral health care extends far beyond our hospitals. Currently, behavioral health clinicians can only meet 28% of the behavioral health needs across the U.S. through in-person care. Virtual care has proven to be equal to or better than in-person visits during the pandemic. This care delivery model is integral to resolving the supply-demand imbalance our country is facing: the divide between patients who are seeking mental health help and licensed clinicians who are available to provide it.

Through our virtual behavioral care solutions in hospitals, outpatient health centers and at-home, Array is bridging divides in access and reducing mental health disparities across the continuum of care, one patient at a time.

Article written by: Geoffrey Boyce, CEO and Co-founder of Array Behavioral Care