Thursday, May 12, 2011

House Subcommittee Hears Presentations on ER Waits and Three-Way Contracts

guest post by Holly Safi


On Tuesday, staff from four NC hospitals presented the House HHS Subcommittee on Mental Health with information regarding services to patients with mental health care needs, particularly long waits in emergency departments (EDs) and the three-way bed contracts the state operates to expand access to inpatient mental health care. A Randolph Hospital official indicated that facility does not have internal capacity for psychiatric care so must hold patients in the ED until transfer is available to an appropriate mental health facility for a psychiatric evaluation. Other hospitals, including the Moses Cone Health System, have psychiatric services but are not equipped to handle some violent patients, and again must hold those patients in their EDs until transfer may be arranged.

A few highlights from their comments:
• One hospital reports the local LME’s crisis team does not respond to emergencies beyond the Monday-Friday work day and encourages consumers with mental health crises to go to EDs on evenings and weekends.
• The same hospital indicated that if a patient has a LME contracted psychiatrist, that psychiatrist ceases service to the patient while in the ED, so psychiatric assessment and treatment is not available until transfer.
• According to the presenters, patients in need of a bed at a state psychiatric hospital wait, on average, 5 days. Some wait as much as 18 days in an ED.
• Long waits contribute to some patients leaving without being seen (approximately 2%).
• Presenters reported this results in disruption of the ED, strains on the hospital staff and security, strains on the resources of local law enforcement, and a safety risk for others in the ED.

Two presenters, one from Pitt County Memorial Hospital and the other from Forsyth Medical Center, discussed the program of three-way beds. The presenters shared the following:
• Goals of the program:
- Increase capacity for inpatients with mental illness.
- Treat patients within their own communities.
- Reduce unnecessary admissions to state hospitals.
- Shorten emergency room waits.
- Facilitate placement of higher needs patients from EDs by giving them priority in transfers to state facilities.
• The three-way bed contracts are contracts between a local hospital, DHHS, and the LME assigned to the area to purchase an expansion of capacity for inpatient psychiatric patients.
• Hospitals are paid a rate of $750 per day per bed by the state. This rate is inclusive of all medical care the patient receives, providing predictable costs for the state but shifting risk to hospitals.
• Many three-way bed patients have medical needs in addition to their mental health needs.
• Robust community supports are necessary to minimize hospitalization.
• Specialty beds for children and adolescents or other patients with special needs are scarce.
• Providers suggested that tiered rates for different levels of care might make the program workable for more providers.

Mike Watson, Deputy Secretary for DHHS, also spoke. Some highlights:
• The State recognizes that wait times in EDs are unacceptable, and much of it is due to lost funding over the last few years which caused hospitals to reduce the number of beds available.
• The State is working to develop additional three-way contracts and increase the number of three-way beds available.
• The 1915 b/c waiver would create incentives for LMEs to keep people out of EDs by requiring them to pay for ED services.

In a March 1, 2011 study by the NC Department of Health and Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, the state gathered information regarding admissions and wait times for the month of November 2010 from 68% of EDs located throughout the state. Some information from that study:
• More than 3% of all admissions to the reporting EDs presented primary behavioral health crises (MH/DD/SA) with a total average ED wait time of 9 hours 38 minutes.
• Of those, 51.1% of behavioral health admissions were discharged home with an average ED wait time of 6 hours 38 minutes.
• 24.3% of behavioral health admissions resulted in psychiatric hospitalization.
- 21.7% were admitted to community psychiatric hospitals with an average ED stay of 14 hours 11 minutes
- 2.7% were admitted to state psychiatric hospitals with an average ED stay of 26 hours 38 minutes

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