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Vastly outnumbered. Ill equipped. Foraging for resources. The nation’s hospital emergency rooms are the Alamo of mental health access and care. The battle for recovery is lost when individuals in psychiatric and addiction crisis have no where to turn.
According to a recent study of the American College of Emergency Physicians, 8 in 10 ER docs say the mental health system is not working for patients.”
This wasn’t what President John F. Kennedy and the architects of the community mental health approach intended. Crisis was one of the five original pillars of the movement, but only in recent years have states, counties and health plans started to invest in these important supports and services.
I’m not going to present a research model. I’m a clinician with an MBA who has worked many years in managed care. I’m going to present the business case for better crisis.
That’s not to say that I’ll give you my guestimates. We’re going to show our math. Think about this a little like the old Jurassic Park movie. I’ve got a strong set of DNA from the Arizona excavation, but it’s got some holes. “That’s where our geneticists take over!” was the line of the mad scientist behind the T-Rex. We have filled the gaps with research findings and data from other large systems.
Michael Schoenbaum in Schizophrenia Bulletin earlier this year showed that young people aged 16 to 30 experiencing first episode psychosis have a much higher death rate than previously thought. He suggests many of these individuals may not even be included in the data set above, despite mortality rates you’d have to compare with 70 year olds in the general population to see similar patterns.
Schoenbaum, M., Sutherland, J., Chappel, A., Azrin, S., Goldstein, A., Rupp, A., Heinssen, R. Twelve-Month Health Care Use and Mortality in Commercially Insured Young People with Incident Psychosis in the United States. Schizophrenia Bulletin, April 6, 2017.
Incoming Call Center Volume Varies, and Varies Widely. If call volume came into centers like a steady flow of water through a pipe, forecasting would not be necessary and planned resources would be simple. Instead, volumes are more like waves at the beach hitting the shore, and each one is different. Think about 15 minute increments being the waves that roll into the beach at the Georgia Crisis and Access Line (May 4, 2015). Between 8am and 5pm those 28 waves varied from the lowest being about 20% of the average and the highest being nearly 200% of the average.
There are also significant variations by day of the week, and season to season.
There are now readily available and inexpensive workforce management software tools that continuously evaluate historic 15 minute by 15 minute data rates to forecast and predict future volumes.
We’ve estimated the volume in this AnyBigCity at 99,000 visits, based upon our volume data in the Phoenix area. We’ve also reverse engineered the TAC 50 bed per 100,000 model and believe it maps very closely to our experience.
The Impact of Psychiatric Patient Boarding in Emergency Departments article from earlier referenced 35% going to inpatient and a cost/loss of $2,264 per person (over the course of an 18 hour average ED wait). 99,000 visits denominator
Bureau of Justice Assistance references the Madison, Wisconsin experience that law enforcement contacts with mental health required 3 hours each. We certainly have many reports of law enforcement being asked to spend much more time, but this seems like a reasonable metric.
There is an assumption among policymakers that psychiatric boarding is the result of a loss of sufficient capacity and there’s a number of beds that would solve the problem. That belies a misunderstanding of the referral patterns and flow that actually occurs.
8,232 ED visits but 7,409 unique
Beyond Beds Crisis Now Business Case National Dialogues NOLA 2017
The Business Case for
David W. Covington, LPC, MBA
CEO & President, RI International
Dr. Michael Hogan, NYS MH
Officer Nick Margiotta, Retired
Phoenix PD, CIT International BOD
Joy Brunson Nsubuga, RI Crisis
Administrator, NC Crisis Center
Wendy Martinez Farmer, LPC
CEO Behavioral Health Link
Dr. Michael Allen, Professor
Psychiatry & Emergency Medicine
Sarah Blanka, RI Crisis
Administrator, Arizona Crisis Center
Seattle Times (2013): Lack of
space forced those
involuntarily detained to wait
for treatment, on average
three days, in chaotic hospital
EDs and ill-equipped medical
rooms. Frequently parked in
hallways or bound to beds,
usually given medication but
no psychiatric care.
benchmarked boarding times
in their EDs in 2015 but has
since reduced wait times 50%
from the figure cited.
Chappell, D (2013) Policing
and the Mentally Ill:
Boca Rotan, FL: CRC Press)
Madison, Wisconsin data
cited by Ruby Qazilbash,
Associate Deputy Director,
Bureau of Justice Assistance,
August 31, 2017 ISMICC
One study found that 1 in 10 calls for service
involved a person with a serious mental illness
In Madison, Wisconsin, law enforcement found
that behavioral health calls for service take
twice as long to resolve
(3 hours versus 1.5 hours on average)
Disastrous Access to Care Wastes Resources
Washington State North Carolina Person without SMI
In 2014, Washington
State Supreme Court
ruled the waits
Psychiatric Boarding: Long
None Visual, Hearing
Half as likely to be
employed as other
No Disability SMIVisual, Hearing or
What are the Current Real Outcomes?
Life expectancy data WHO
and NASMHPD, and Disease
Prevalence from World
Employment data from
American Community Survey
and NAMI SMI
Nation data from World
Happiness Report (“Someone
to rely on in times of trouble”).
SMI data from AZ Health Risk
Assessments (“Someone to
talk to about problems” and
“Someone invites me out for
“Prevalence of SMI Among
Jail Inmates” and “Poverty
and Severe Psychiatric
Life for the nearly 10
million people with SMI
in the US has
to the average person
Iceland USA SMI in USA Afghanistan
Likelihood of Early
Death by 30%
% of Population w/ SMI % with SMI in Jail
3-5x increase Poverty,
% of Jail Population w/ SMI
Japan USA Afghanistan SMI in USA
2-3x increase Obesity,
According to the American
Association of Suicidology, the 2014
suicide rate for males 65+ was 32
per 100,000, but 51 per 100k for
those over 85.
In 2010, USA Today reported the
US Army suicide rate at 22 per
100,000 but the Fort Hood rate was
47 per 100,000.
The Suicide Prevention Resource
Center (SPRC) reported Alaskan
Native/American Indian males ages
15 to 24 had the highest rate at 28
per 100k. In 2010, USA Today
reported those AN living in Alaska
had a suicide rate of 42 per
The SPRC says little can said with
certainty about death rates for
LGBT youth due to limited data
collection. Other research suggests
two three times the national rate.
In 2008, a UK study by Osborn
found the hazard ratio for
individuals with SMI, including
Schizophrenia, to be nearly 13
times the general population. In
2010, King’s Health Partners found
the risk to be 12 times greater
during the first year following
diagnosis of a serious mental
While rare, incidents of individuals
with SMI who were untreated being
involved in the tragic deaths of
others have garnered the attention
of our national dialogue.
Thousands Die Alone and In Despair
Suicide Rate: HazardRatiovs.GeneralPopulation
White Males 65+
In 2013, Virginia State Senator Creigh Deeds told
CNN he was alive to work for change in mental
health. A week earlier, he was stabbed multiple
times by his son, who then died of suicide. This
happened hours after a mental health evaluation
suggested “Gus” needed more intensive services.
Tragically, he was released before the appropriate
care could be found.
Calculated from BJA presentation at ISMICC (2017), Madison, Wisconsin data
Saved hospital EDs $37m in
Reduced total psychiatric
boarding by 45 years
Calculated from “Impact of psychiatric patient
boarding in EDs” (2012) (Nicks and Manthey)
Reduced potential state
inpatient spend by $260m
Calculated from Arizona data, 2017
The Crisis Now Difference
Saved equivalent of 37
FTE police officers
In 2016, according to Aetna/Mercy Maricopa, metropolitan area Phoenix law enforcement engaged 22,000 individuals that they transferred directly to crisis
facilities and mobile crisis without visiting a hospital emergency department. What difference did it make?
Improved Crisis Clinical Fit to
Need (CCFN) by 6x
Fire savings just starting.
Crisis Now Continuum System
Level 1 Level 2 Level 3 Level 4 Level 5
Crisis Now: Transforming
David W. Covington, LPC, MBA
CEO & President, RI International