Effective case management of psychiatric patients in the ED
The most important aspect to remember about psychiatric patients in the ED is to help them and their families (if present) feel safe. Consider following these 10 principles:
- Pay attention to the patient as a hero of their own story
- Use your gut to tell you what is going on, not your brain
- The symptoms you are observing may be an acute onset or a chronic condition
- Start where the patient starts
- Be positive
- Always give the patient CONTROL
- Share your ego with the patient
- Pay attention to HALT: Hunger, Anger, Loneliness, Tiredness
- Bottom line: the patient needs to know he/she is safe with you
- Don’t “do to” psych patients, do with them
The toughest patients are those with personality disorders, anxiety, depression, and bipolar conditions, as well as substance use disorders. One out of every eight ED visits are psychiatric patients. See below for the percent of diagnoses vs. billing, according to AHRQ:
Diagnoses:
- 42.7% mood disorders
- 26.1% anxiety disorders
- 22.9% alcohol-related conditions
- 8.3% drug-related, schizophrenia, psychoses, intentional self-harm
Billing:
- 30.1% Medicare
- 25.7% private insurance
- 20.6% uninsured
- 19.8% Medicaid
The really good news is that the behavioral health continuum is increasing in size and capabilities. Besides inpatient beds, there are partial day programs, crisis units, shelters, group homes, peer coaches, outpatient care, and group therapy. There are also Community Crisis Teams and Assertive Community Treatment (ACT) Model:
- Professionally skilled staff deliver psychosocial and pharmacological interventions
- Available seven days/week
- Shared caseloads
- Direct services in community
- Mobility
- Responding to crises
- Policy to not close cases
- Controlled rate of admitted new cases (caseload average = 1 case manager per 10 clients)
For more information, see Case Management Models: Best Practices for Health Systems and ACOs, Second Edition.