Emergency departments are no doubt facing increased demands due to a number of factors, including limited access to primary care, an increase in uninsured Americans, and a growing aging population in need of care. It is also, in many cases, the primary point of care for patients in need of behavioral health care.
If the success of an emergency department is measured by its throughput, as most are, finding ways to improve it — while juggling a host of unpredictable variables — is one of those recurring quests that healthcare administrators find themselves chasing. For some, telebehavioral health support integrated directly into the emergency department has offered relief.
Iris Telehealth’s chief medical officer Dr. Tom Milam recently discussed emergency department throughput challenges and telebehavioral health solutions as part of a webinar panel hosted by the Scottsdale Institute, a non-profit health system membership organization committed to advancing healthcare’s digital transformation in an equitable, patient-forward way.
Dr. Robert Bob Trestman, a professor and chair of psychiatry and behavioral medicine at Carilion Clinic in Virginia, and Dr. Matthew Harbison, who oversees behavioral health at Memorial Hermann in Texas, also joined the panel. Milam and Iris partner with both Trestman and Harbison in a telebehavioral health capacity in their emergency departments. Each faces their own unique challenges.
At Carilion Clinic, a healthcare system with seven hospitals and six emergency departments serving the eastern edge of the Appalachians, Trestman said a recent emergency department expansion to the size of an actual football field still doesn’t provide enough space — or any dedicated space for psychiatry.
“We don’t have the capability to meet the demands of the turnaround times necessary,” Trestman said. “We’re always at a tension between those who do screening and psychiatric management. The faster we can make an accurate assessment and determine triage, that is the coin of the realm and that’s the challenge that we’ve been facing with increasing acuity and complexity year over year.”
At Memorial Hermann in Houston, which provides the highest amount of safety net care across its 14 acute care hospitals in that region of Texas, Harbison said there is a need and vision for restructuring the emergency department so it views treatment for behavioral health conditions with a thought process that mirrors treatment for physical conditions. With the support of Iris, Harbison is encouraging a shift in perspective.
“Most folks in Houston, their first access point to behavioral health is the emergency department,” Harbison said. “It’s the least friendly place for a behavioral health crisis. The long-term goal with Iris and other partners is to build an ambulatory platform that catches a crisis so the emergency department isn’t the entry point for behavioral health care.”
While each of these challenges is unique to the patient population predominantly served by the two systems, with one managing substance abuse disorder more often and the other working with a high percentage of cash-pay patients, telebehavioral integration is assisting both with throughput. Milam said the differences between the two environments highlight the versatility of a telebehavioral health partnership with Iris.
For Milam, it all starts with asking questions. He asks simply what has worked, after looking at the varied initiatives an emergency department has tried, from mobile behavioral health with law enforcement to ambulatory access to tailored avenues for detox for unhoused patients.
“I don’t think anybody is doing anything wrong,” he said. “I think it’s the system we’ve created, where the emergency department is the point of access.”
The barriers to behavioral health care discussed during the webinar included reimbursement issues, reduced stigma for behavioral health care, and limited resources outside of the emergency department. Many of the barriers are influenced in some way by each other, as — for example — reimbursement challenges encourage providers to turn to a private-pay practice rather than dealing with insurance.
Working within the confines of the system, administrators in search of improved efficiency and emergency department performance are finding success with telebehavioral health.
“As we all know, the folks who have the least access are the most vulnerable and often need the services the most,” Milam said. “Virtual care has been a win for getting providers into remote locations where they couldn’t recruit. It’s also good for people working in multiple, different locations.”
At Memorial Hermann, Harbison said the Iris partnership has facilitated a significant improvement in the time between when an order for a behavioral health consult is ordered and when the patient sees a prescriber. Prior to Iris, it was between 9 and 15 hours. Over the most recent two month period, it measured just two hours. Carilion Clinic noted the same two-hour time span.
“The person that matters is the person who can prescribe you the intervention that’s important,” Harbison said, noting that prior to Iris the first contact for a patient had most often been a licensed clinical social worker. “If I can get appropriate medications initiated, I could avoid those inpatient transfers, which is the ultimate goal.”
At Carilion Clinic, Trestman said emergency department doctors are not comfortable treating psychiatric conditions, but “there’s no one to hand them off to.” With integrated, telebehavioral health support, the clinical landscape has changed. Assessments aren’t delayed and services are available 24/7.
“It’s really an incredibly valuable opportunity to partner with others who can, through scaling, use telehealth services to provide high quality diagnostic assessment, treatment recommendations and appropriate disposition recommendations very quickly,” Trestman said. “Providing that level of service makes the emergency department happy. Everything works better when we’re not clogging the emergency department with longer stay patients.”
To learn more about how the solutions offered by Iris Telehealth could improve emergency department throughput for your health system, click here.
