Individuals with mental health conditions are presenting to emergency departments (EDs) at steadily increasing rates. According to the Agency for Healthcare Research and Quality, between 2006 and 2013, there was a 55.5% increase in the number of ED visits for depression, anxiety, and stress reactions; a 52% increase for psychosis and bipolar disorders; and a 37% increase for substance use disorders (Weiss et al., 2016). These increases can be accounted for not only by the mental health condition itself but also by medical comorbidities that are often poorly managed or worsened, secondary to mental illness (Capp et al., 2016). As a result of these increasing rates of psychiatric admissions, EDs must frequently attempt to treat the mental and physical problems of this patient population. Boarding of patients increases, which leads to treatment falling short of providing holistic and effective mental health care (Nordstrom et al., 2019). Subsequently, many EDs are implementing alternative models of care to more effectively manage patients with mental health conditions. One such model includes peer support specialists (PSSs) in ED settings to offer support and recovery-oriented interventions.
The purpose of the current article is to describe an ongoing pilot project at an ED that employed PSSs for assistance in management of patients in mental health crises. Current models of psychiatric crisis management and the role of PSSs will be discussed.
Models of Psychiatric Crisis Management
The increased number of patients presenting to EDs in psychiatric crises has motivated health care providers to seek creative ways to manage this patient population. Models of psychiatric care may reside within EDs, offering on-the-spot psychiatric interventions, or they may reside at off-site locations, specifically intended to remove patients from general EDs and get them quickly to more appropriate, off-site care. Regardless of the setting, the primary goals are to decrease unnecessary psychiatric hospitalizations and improve patient care. A secondary goal is to decrease ED boarding costs.
An increasingly common model of care involves the use of crisis stabilization units (CSUs). CSUs are typically located within EDs but are occasionally located in the community outside of the ED. Regardless of location, it is typical for mental health care providers in CSUs and EDs to work closely on issues, such as medical clearance. Individuals in mental health crises, but cleared of underlying physical symptoms, will be sent to CSUs for potential stabilization and avoidance of an inpatient psychiatric hospitalization. The Child & Adolescent Rapid Emergency Stabilization (CARES) program in Connecticut has shown promising results for this CSU model. When patients are identified as needing psychiatric services and are cleared by the ED, they are then transferred to the CARES unit located in a separate facility. Psychiatric professionals at CARES then provide assessment, stabilization, and case management with an emphasis on the importance of family and community supports (Rogers et al., 2015). By doing so, unnecessary inpatient psychiatric hospitalizations can be avoided. The length of stay in the ED and subsequent cost of the ED visit were found to decrease significantly (Rogers et al., 2015).
One of the more promising CSU models is the Alameda Model in California (Zeller et al., 2014). Under this model, patients in psychiatric crises are taken to a stand-alone psychiatric emergency service (PES) unit where they receive care from psychiatric professionals. Patients can be admitted to the unit by direct transfer from an area ED, ambulance transport, or patient walk-in. Goals of the PES unit are symptom stabilization and crisis de-escalation within 24 hours to avoid unwarranted inpatient psychiatric hospitalizations. Results of the Zeller et al. (2014) study showed that 75% of patients who accessed the PES unit did not require inpatient psychiatric services. Boarding times for psychiatric patients in five area EDs also decreased significantly to 1 hour 48 minutes, compared to the state of California's average boarding time of 10 hours 3 minutes for the previous year (Zeller et al., 2014).
Models of care targeting patients in psychiatric crises directly within EDs are less common. Several barriers, such as space and staffing, make implementation within EDs more difficult. Psychiatric consultation services are typically used with this model, wherein psychiatric professionals, qualified to examine patients in psychiatric crises, come to the ED on a case-by-case basis. However, a study by Woo et al. (2007) found that when compared to psychiatric services provided within the ED, such professional consultation services increased the time from admission until psychiatric evaluation, the use of emergency medications, the use of restraints and/or seclusion, and incidences of elopement.
One model of care, successfully implemented within an ED, specifically targeted the pediatric and adolescent population. The Family-Based Crisis Intervention program was implemented within an ED to address suicidal ideation among adolescents (Ginnis et al., 2015). Ginnis et al. (2015) sought to provide care within the ED instead of waiting for admission to a psychiatric unit. This approach mirrors the way physical medical conditions are addressed within EDs. In this model, psychiatric clinicians meet with the adolescent patient and family members for a single session to provide cognitive-behavioral skill building, assess and increase readiness for therapeutic intervention, and provide psychoeducation. Safety planning is also a major component of this model (Ginnis et al., 2015). These family-based interventions have the potential to avoid psychiatric hospitalization if the patient is successfully stabilized within the ED.
Is There a Role for Peer Support Specialists in Emergency Departments?
PSSs (also known as peer providers and peer counselors) are individuals who are in recovery from their own mental illness. Inclusion of PSSs within EDs and other settings presents an opportunity to improve psychiatric crisis intervention and recovery. Through both lived experience and formal training, PSSs develop skills to provide mental health care to individuals in psychiatric crises (Substance Abuse and Mental Health Services Administration [SAMHSA], 2019). PSSs are the cornerstone of the Recovery Model, which focuses on restoring quality of life as defined by the client's goals and desires.
A literature review conducted by Mental Health America (MHA; 2018) identified several positive outcomes supporting the use of PSSs. For example, use of PSSs led to a decrease in hospital bed days, a decrease in hospital readmissions, and an increase in the use of out-patient services, all of which contributed to lower costs of care overall. Quality of life also improved for clients through increased rates of employment, socialization, and feelings of hope (MHA, 2018). A review of programs focused on peer-delivered health and wellness services across three states supported PSSs' ability to bridge treatment gaps in the mental health care system and provide unique emotional support to clients (Swarbrick et al., 2016).
PSSs have been a cornerstone of “The Living Room” model of care and have shown promising outcomes. “The Living Room” is a community-based crisis respite center meant as an alternative to EDs. In this model, PSSs provide one-on-one support to individuals in mental health crisis. Outcomes from a 30-day follow-up survey supported that the use of PSSs within this model's frame-work was effective for preventing ED use for a psychiatric reason (Heyland & Johnson, 2017). Clients using “The Living Room” also found their work with PSSs to be beneficial as they offered empathic, nonjudgmental support, communication, and rapport building (Shattell et al., 2014).
Given these positive outcomes, PSSs would appear to be a valuable addition to the psychiatric treatment team in clinical settings. Having lived experience with mental illness, PSSs are uniquely positioned to offer essential crisis intervention services. Particularly useful is their ability to provide immediate crisis intervention and de-escalation by offering clients effective communication, compassion, and support. Because PSSs have lived through various stages of their own mental illness, they are able to provide useful, timely, and appropriate therapeutic interventions (SAMHSA, 2019). The efficacy of verbal de-escalation helps prevent other problems, such as use of nonessential emergency psychiatric medications and restraints.
Patient boarding in EDs is a significant issue, particularly for mental health patients (Nordstrom et al., 2019). If de-escalation is effective, PSSs may aid in faster discharge of the patient from the ED and less need for inpatient psychiatric beds. If de-escalation is not effective, PSSs can use their time to work with the patient on longer-term treatment planning (SAMHSA, 2019). PSSs also provide off-site resource referrals and essential linkage to ongoing care beyond the ED (Gagne et al., 2018). As a result, ED recidivism can decrease as patients secure consistent and effective providers and services to address their own mental health needs.
PSSs have been used in the ED setting specifically with patients with substance use disorders (SUDs) (Ashford et al., 2019). In this role, PSSs were assigned to patients who were admitted with an opioid overdose or were diagnosed with a SUD. Results showed a high rate of engagement between PSSs and patients. PSSs offered referrals to various levels of care, from withdrawal management and recovery residences to community-based supports, such as warm lines. In doing so, PSSs provided a “bridging of gaps between social support and formal clinical support” (Ashford et al., 2019, p. 23).
PSSs also address a missing element in ED services that psychiatric patients have identified. When presenting to EDs, patients experiencing psychiatric crises often believe there is no one to talk to and that their psychiatric issues are not prioritized (Clarke et al., 2007). Instead, they are often moved to a secure, yet sterile room with a security guard but no one offering assistance. In such cases, PSSs can provide the kind of ongoing support and communication that patients need and desire (Lyons et al., 2009; SAMHSA, 2019).
Today, PSSs are being integrated into traditional mental health treatment settings more frequently than in the past (Gagne et al., 2018; Gillard et al., 2017). As a result, standards of care are being established that allow for PSSs' autonomy while still ensuring high-quality outcomes. Research summarized by SAMHSA (2015) resulted in a list of core competencies for PSSs applicable to their roles in behavioral health care settings. In addition, a meta-analysis by Gillard et al. (2017) identified principles of peer support that include safe relationships built on the foundation of trust, mutual respect, empathy, and promotion of the use of PSSs' experiential knowledge. Key principles for organizations employing PSSs include empowerment of PSSs to make choices and assume control within the relationships they form (Gillard et al., 2017).
Implementation of Peer Support Specialists in Emergency Department Project
As part of a grant through DuPage County's National Alliance on Mental Illness (NAMI), PSSs were recently incorporated into the ED of a hospital in suburban Chicago. The “Peer Counselors in the Emergency Room Program” is operated by NAMI DuPage with the goal being “to help reduce unnecessary and counterproductive ED visits for individuals experiencing a mental health crisis” (NAMI DuPage, 2018a, p. 1). One PSS is assigned to the ED staff during a given shift. Shifts are currently Monday, Thursday, and Friday from 3 p.m. to 8 p.m., which coincides with times when the number of patients in mental health crisis is highest in the ED. In this role, PSSs frequently check in with a designated ED clinician to determine whether there are any patients whom the PSS may be able to assist.
If a patient is deemed appropriate by the clinician, the PSS's role is to provide support, comfort, education, and encouragement to the patient (NAMI DuPage, 2018b). Importantly, the PSS educates the patient on the availability and services offered by “The Living Room,” which the patient is encouraged to use instead of the ED for future mental health needs. If there are no appropriate patients in the ED, the PSS may be sent to the inpatient psychiatric unit to assist with groups or provide one-on-one mentoring of current inpatients. When not meeting with patients, PSSs conduct follow-up phone calls with patients who have previously been seen in the ED and have consented to participate in such follow ups. These follow-up calls are completed 7, 30, and 60 days after the patient's initial visit with the PSS (NAMI DuPage, 2018b).
A variety of preliminary outcome measures are being collected to determine the efficacy of this pilot to use PSSs in the ED. Of 65 individuals who signed consent forms agreeing to participate in follow-up telephone calls, only 17 provided responses. It should be noted that this leads to a large nonresponse bias. The mean time to receive a response was 20.3 days. Four individuals' responses did not have an annotated response interval.
During follow-up conversations, patients were asked to describe what they found most helpful about their interactions with PSSs while they were in the ED. During these conversations, patients' verbal descriptions of their interactions with PSSs were coded based on selected key terms. For example, those respondents who described their PSS using words such as “empathetic,” “caring,” “understanding,” “connecting,” or “open” received a code for “empathy.” Use of this synonym-based coding system revealed four major areas of interaction that patients found most helpful. These were: “empathy” (35% of respondents), “information” (23.5% of respondents), “talking” (17.6% of respondents), and instillation of “hope” (0.5% of respondents). Approximately one quarter (23.4%) of respondents did not respond with words related to any of these areas of interaction. These responses reflect themes in the literature that depict patients' desires to have these types of support (Lyons et al., 2009).
Regardless of the nature of the interactions with PSSs that patients found most helpful, all respondents reported that having a PSS in the ED with them was beneficial. This was true regardless of the patient's intention to use alternatives to the ED, such as “The Living Room,” in the future. Of those who responded to a question about their future intentions, 64% said they did not intend to use this type of off-site psychiatric service. Importantly, regardless of their intention to use off-site services, 82% of respondents had not returned to the ED in the time between their initial hospitalization and the time of the follow-up phone call. This tentatively confirms the finding of the MHA (2018) report that use of PSSs can decrease hospital readmission rates. However, it should also be noted that the time of the follow-up phone call varied depending on the success of reaching the respondent at certain intervals, with an average response time of 20.3 days as noted previously. Of the 18% who returned to the ED, only 12% reported that their hospitalization was due to suicidal ideation of self-harm, suggesting efficacy of the PSS intervention to help patients navigate future crises and respond appropriately. The other 6% went back for medication adjustments. Although preliminary, these positive outcomes lend support for the use of PSSs in EDs.
Discussion and Future Recommendations
Although these initial outcomes seem promising, additional research regarding the effectiveness of PSSs in the ED setting is needed. In particular, the high nonresponse rate will need to be addressed. For instance, one of the unanswered questions is whether respondents and nonrespondents to follow-up requests differ in some specific way. In addition, standardized follow-up protocols and a well-designed questionnaire must be used to increase the reliability of the results. As such, the current data-set should be seen as preliminary results of a pilot program and the beginning of a much larger and more comprehensive study.
The preliminary results reported suggest there is value in having PSSs involved with psychiatric patients within ED settings. Of particular value is their apparent ability to reduce the future reliance of psychiatric patients on EDs for their mental health needs. In both the existing literature (Heyland & Johnson, 2017; Swarbrick et al., 2016) and in the current project, PSSs were shown to be effective in communicating with psychiatric patients and intervening in the cyclical nature of ED admissions for individuals in mental health crises. As such, the use of PSSs in EDs has the potential to decrease ED boarding by patients with mental illness and decrease adverse patient outcomes secondary to psychiatric crises, such as the use of restraints and emergency medications. PSSs also increase the opportunity for interdisciplinary collaboration in EDs. Thus, inclusion of PSSs is recommended as a novel model of care within EDs or as an adjunct to existing models of care.
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