Lift the Fog of Emergency Admissions and Optimally Use Levels of Care

Our field should unequivocally strive for fewer hospital admissions in the fog of an emergency. The problem is not our hospitals. The seeds for changing inpatient care patterns are best planted early in the outpatient setting. We need better ways of finding people at risk for a potentially dangerous crisis. We then need skilled clinicians to engage and stabilize them from a biopsychosocial orientation.

Ours is a unique specialty. There are surely instances of emergency surgeries, but most are routinely scheduled. However, acute behavioral admissions, for mental or substance use disorders, are mostly unplanned. The regrettable norm is to wait for a life-threatening crisis to emerge. Yet many emergency admissions are wholly predictable and even preventable, if only our systems were designed for that.

Prevention exists on a continuum. Some emergency admissions can be diverted at the last minute. Crisis specialists understand we can all experience events which trigger a crisis. One’s trusted coping strategies stop working. This can escalate into a dangerous situation, but fortunately, a crisis can also be therapeutically and safely resolved. However, our goal should be earlier intervention prior to crisis.

Our behavioral healthcare system is exemplary in its design of escalating levels of care for both mental and substance use disorders. The problem we have is operational. How do patients actually flow through these levels? For example, we stabilize patients at the inpatient level and step them down to intermediate care. However, moving patients in the other direction is not as smooth, nor as routine.

We should focus on interrupting the seemingly inevitable progression to inpatient care. Admissions too often proceed from outpatient care or none at all. Why? Outpatient behavioral care is specialty care. People do not see behavioral clinicians annually and then more frequently as needed. That is generally reserved for primary care. Many have argued behavioral care should be part of primary care.

Incorporating outpatient behavioral care into primary care would potentially impact every level of care. It facilitates using intermediate levels of care (e.g., intensive outpatient or partial hospitalization programs) to stabilize people a few steps short of inpatient treatment. A delivery model with primary behavioral care means that more people are screened for emerging crises. Time becomes an ally to design intensive interventions.

This is equally relevant for mental health and substance use disorders. Both can progress unchecked into full-blown clinical disorders, with treatment starting during a dangerous crisis because earlier recognition has failed. Only about 10% of those with substance use disorders (SUDs) get needed care because early detection and intervention is sadly lacking. Asking primary care physicians (PCPs) to use screening tools is gravely inadequate and burdensome.

Rather than adding to demands on the PCP, the pivotal change we need is transforming behavioral care into routine primary care. We would still require each level of care, but patient volumes would necessarily change. Fewer people would need acute inpatient care, many more would engage in outpatient care, and intermediate care would more often be used as an urgent step up from outpatient.

One benefit of optimally using each level of care would be less conflict between payers and providers over the necessity of inpatient care. Many physicians and care managers engage in reviews that would hopefully become more collaborative. Such discussions might even be replaced over time by aggregate monitoring and the appropriate scaling of treatment resources.

We can reach a point where fewer people are hospitalized in the often chaotic throes of an emergency, but it depends on many changes in the structure and utilization of outpatient services. In addition to psychiatrists and therapists working comfortably in frontline primary care, we will also need specialists working intensively with complex cases outside the primary care arena. We are not yet there today.

Our field’s deficits must be discussed. Too many therapists still feel uneasy discussing a client’s suicidal ideation. Others dismiss SUD as a specialty issue they need not explore. We should clarify core competencies needed in our field, focusing on two types of essential outpatient clinicians—those excelling in brief primary care encounters, and those skilled at working with vulnerable, at-risk clients.

How long can we tolerate a majority of those needing our services being unable to access them? How long can we accept acute admissions that would be preventable in an outpatient-heavy delivery system? We are entering a period of change as health plans and health systems acquire and integrate our behavioral capabilities. Before the status quo is immovable, let us change how we use our levels of care.

Ed Jones, PhD, is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health. Chris Dennis, MD is the chief behavioral health officer for Landmark Health and co-founder of Minded.

The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.