Editor’s note: This commentary is by John McClung, of Danville, who has been a psychiatric nurse for over 35 years. He has worked in Vermont for the past 10 years at both Central Vermont Medical Center and Northeastern Vermont Regional Hospital.
[I] continue to hear about the ongoing issues and problems that patients with mental disorders face in hospital emergency rooms. Yet with everything I have read and listened to, I have yet to understand the core problem that is at the root of this ongoing crisis. Some speak of “long wait times,” others say “lack of trained staff,” still others “that the ER environment is too chaotic and overstimulating.” While all of this is certainly true, they are only symptoms of a single core problem that patients with mental disorders face in the ER.
To me the answer seems so obvious that it is either invisible because of its simplicity or ignored because of its complexity. The core problem with patients that have mental disorders being treated in a hospital ER is: Patients with mental disorders are being treated in a hospital ER.
It’s just that simple.
If the patient had never gone to the ER then all of the issues with them being there would never manifest. Now this should come as no surprise to anyone when you consider a hospital ER is designed, built, staffed and structured around a culture of caring for patients with physical disorders. Of course a person with a mental disorder will have a difficult time being treated and cared for in such environment. What is a surprise, at least to me, is how quickly this basic truth is dismissed with cries of “there is no choice” or “that’s how the system is set up” or “they have to be medically cleared before they can be placed elsewhere” or the big one, “where else can they go?” If we accept this basic truth, that their being in the hospital ER is the core problem, then we may be at a point of looking for a better systemic solution.
Even in the current dysfunctional system however, emergency rooms across the state are beginning to make progress in the care and treatment of patients with mental disorders. Recognizing the need for trained staff, a calming stable environment and a separate care area, are excellent first steps. Most hospitals independently are trying to do some or all of these needed changes to their ERs, and depending on the level of their administrative and financial commitment, any results will take time and may well be spotty across the state. Even then, most “separate care areas” will only accommodate a limited number of patients, continue to only be a holding area, and once those beds are full the ER is back to where it started. It seems to me that a better option would be for hospitals to collaborate and use their combined resources for a separate psychiatric emergency department.
Fortunately there is already such a model and it has been in effect for a number of years now with excellent results in a decrease need for inpatient hospitalization and an increase in discharges back to the community or home. Most know it as the “Alameda Model” but there are various ways to structure it according to the needs of the community.
It is quite simply a regional psychiatric emergency department. The concept is simple. The same way current ERs are designed and staffed for patients with physical disorders, a regional psychiatric emergency department would be designed and staffed specifically for patients with mental disorders. Two or more hospitals in a given regional area would combine their resources into one regional psychiatric emergency department. All patients with mental disorders in that given region will be taken directly there by EMS, police, families or walk-ins. Any individual with a mental disorder who ends up at a local ER can be medically cleared and transferred to the regional psychiatric emergency department quickly, thus alleviating the current problems that ERs are now experiencing.
This is not just a holding area like ERs in the state are now, but patients would be treated from the moment they come in. The need for inpatient hospitalization decreases substantially with quick treatment and involvement by trained staff.
For those individuals still needing inpatient hospitalization this centralized hub model has several advantages:
• Vital resources focused in one area instead of thinly spread out across the region
• Social workers and case managers can consolidate and prioritize patient information in real time, thus helping to find placement much faster and much more cost effectively.
• Hospitals will not have to compete against each other for the replacement of patients.
• Level one beds may not be needed as much, due to the prior stabilizing care and treatment that the patient has already received, thus potentially qualifying them for less acute and faster bed placement
Now at this point one may rightly ask, “If this is such a great model why haven’t Vermont hospitals embraced it?” Quite honestly, I really don’t know.
Perhaps they are not aware of it, but I’m sure that I’m not the only one that knows about this concept or has access to the Alameda models information and data (it is easily accessible on any website). Perhaps they have considered and dismissed it, or felt that it was too much or too overwhelming to pursue. I really couldn’t say but I would guess that hospitals are just now beginning to realize and accept the fact that this problem is not going away and the state is not going to provide them all the beds they want for quick mental health placement. At the same time, they are being hit by CMS inspections and subsequent required changes to their hospitals. So they are now playing catch-up and probably just doing what is needed to pass the next inspection, and not looking for a more comprehensive solution.
Now this model may or may not be possible in Vermont. However, we will never know if it is workable or not until hospitals seriously consider it and talk among themselves about its possibilities. I would encourage all reading this article to contact their local hospitals and legislators and ask them about it.
