Taking Substance Abuse and Mental Health Out of the Emergency Department

Ed's Note: This article is reprinted from the inaugural issue of Integrated Healthcare Delivery. To subscribe, visit IHDelivery.com.

In early 2008 a presentation at the Gathering of the Eagles conference in Dallas focused on “The Paramedic Paradox: Is Less Really More?” The concern expressed by speaker J. Brent Myers, MD, MPH, medical director for North Carolina’s Wake County EMS, related to paramedics with sparse annual experience providing care in complex medical situations requiring a high level of skill.

He noted that creation of an advanced-practice paramedic could address issues resulting from high-volume consumers as well as those in need of acute mental health care, while also functioning in an integrated role with other community health programs. Soon after this Wake County EMS initiated its first advanced-practice paramedic academy.

The academy hosted 19 APP candidates in an intensive eight-week competitive process that involved more than 300 hours of didactic and clinical training. The additional training covered items such as advanced clinical decision making, additional assessment tools, an in-depth pharmacology review, and the epidemiology of substance abuse and mental health issues. It included a Crisis Intervention Team (CIT) certification course provided by the National Alliance on Mental Illness-North Carolina. At the conclusion of the academy, 14 graduates were selected to function as full-time APPs, with the remaining serving as fill-ins where needed.

On January 6, 2009 the APP program was officially launched. Five units during the day and two at night would serve approximately one million persons over 856 square miles. Since its implementation, the APP program has grown to include two direct supervisors, one for each shift.

The APP program was implemented as a supplement to the paramedic/EMT deployment model utilized by Wake County ambulances. Its motto is Respond, Reduce and Redirect. The APPs focus on responding to high-acuity calls within the EMS system, as well as building and strengthening relationships with community partners such as the Wake County Department of Human Services and various homeless shelters, substance abuse rehab facilities and mental health facilities. The APPs work to become integrated into the community as a resource for finding and addressing patients underserved by the traditional healthcare system.

APPs are automatically dispatched on a myriad of different call types as an addition to fire department first responders and ambulance crews. They have a significant impact on the health of those experiencing substance abuse and/or acute mental health crises. Once these patients are identified as potential candidates for destinations other than hospital emergency departments, they are screened by an APP for appropriate placement.

Alternative-Destination Screening

The alternative-destination screening process used in Wake County focuses on patients who have as their primary complaint mental health or substance abuse issues or suicidal ideation without an actual attempt. During the EMS encounter, they are evaluated using two standing-order EMS protocols: Behavioral and Well Person (see Figure 1). Patients who are not combative or agitated, do not require sedation and are cleared by the Well Person protocol are additionally evaluated by an APP. The APP utilizes the Medical Screening Checklist for Admissions (see Figure 2). As the program has matured, it has become apparent that some individuals can be screened remotely, thus facilitating more rapid movement to their destination.

After the alternative-destination screening is completed, the patient can be referred to one of the Wake County community health partners that offer mental health services or substance abuse rehabilitation. In all cases the APP completes a phone consultation with personnel at the appropriate facility for potential placement. Law enforcement or EMS may provide transport to these locations; there the APP completes their care with a face-to-face report. Additionally, the APP completes the Crisis Intervention Paramedic Form (see Figure 3).

The goal of the alternative-destination program is getting the right services to the right patient at the right time rather than just providing transport to the emergency department. If the patient refuses the recommended alternative destination, we offer transport to the emergency department if they choose. 

Wake County APP Partners

The Wake County EMS APP program has built strong relationships with mental healthcare agencies throughout Wake County. These have assisted and made possible our alternative-destination program. In order to triage, treat and manage the mental health population outside the emergency department, other facilities and agencies must work cohesively with EMS. Our partners are:

WakeBrook Recovery Center—Patients in emergency custody or under involuntary commitment orders are sent to this facility, operated by the University of North Carolina, for initial assessment and triage. Others looking for mental health assistance can seek it at WakeBrook voluntarily. Once assessed by on-site clinicians and psychiatrists, the mental health patient will either be sent for inpatient hospitalization or given local outpatient mental health follow-up resources. The WakeBrook campus also offers an alcohol treatment and recovery center. Patients wanting assistance with their addiction to drugs and/or alcohol can be assessed and placed in medical detox beds on site.

Holly Hill Hospital—A private mental health facility that specializes in psychiatric and addiction care, this facility serves the entire mental health population, including children, adolescents, adults and geriatrics. As part of our program they accept patients from all payer sources.

The Healing Place of Wake County—A nonprofit recovery and rehabilitation center for people with alcohol and/or drug dependency, this center has a step-by-step approach to fight addiction. The steps range from an overnight shelter to a residential recovery program. The residential program has different phases intended to help break addiction while one lives and cares for oneself. Their program can last up to 12 months and also assists with job and housing placement.

Alliance Behavioral Healthcare—Alliance is a managed-care organization that provides an overview of services available to mental healthcare patients in the Wake metro region. Anyone can access Alliance via telephone and receive a behavioral health assessment 24 hours a day. Callers can get access to providers, physicians and agencies for which they qualify. The APP can call Alliance and work with them and the patient to find the resource best suited for the patient in crisis. This could mean taking the patient to one of the above facilities or scheduling an outpatient follow-up for the next day.

Results

Wake County EMS began collecting data on alternative transports to mental health and substance abuse facilities on July 1, 2010. In the following six months, the APPs successfully diverted 126 patients to facilities other than EDs. This suggested we might expect around 250 patients in a full year of the program.

In that first full year, 2011, the program assisted 212 patients, then 252 in 2012. Due to expanding partnerships in the community, the number of transports to alternative destinations has increased dramatically; as of December 18, 2013, it stood at 350. Patients are being redirected appropriately; for instance, between January 1 and October 1, 2013, WakeBrook received 171 patients diverted from area EDs through our program. Of those, only 24 were subsequently redirected to emergency rooms for complaints during their stay.

These numbers, however, only begin to explain the true success of the program and the impact it is having on healthcare in Wake County. An average length of stay at the main crisis center in Raleigh is just over 14 hours before the patient is either admitted to a state mental health facility or referred back to their primary psychiatric provider. A chest pain patient who arrives at the ED requires, on average, three hours for initial evaluation and treatment. Therefore, each mental health patient diverted away from an ED not only receives more appropriate care but also could allow more than four chest pain patients to be evaluated in the same time frame. With increased ED overcrowding and wait times, the alternative-destination program’s benefits can be felt community-wide.

Further efforts are underway to increase the number of mental health and substance abuse patients diverted. Over the last four years, an average of 800 patients a year fail the screening criteria, and another 175 have refused transport to a mental health facility. Along with our community partners, Wake County’s APPs are working to increase the number of mental health and substance abuse patients receiving appropriate treatment at appropriate facilities while reducing demands on local emergency departments.

Conclusion

An area of need had been identified in emergency medicine. Working with community partners, the Wake County EMS system is striving to find the best possible care for its mental health and substance abuse patients. Having a comprehensive screening process allows us to redirect patients safely to an appropriate care facility. An individual in need may not always know where to look or how to ask for help. It is the objective of this program to assist each person in locating resources that are most effective for their situation. As of December 18, 2013, 940 people have been assisted through this program, and many more will have the opportunity with continued support.

Greg Guillaume, EMT-P, has been a paramedic for 10 years. He is entering his sixth year at Wake County EMS, two of which have been as an advanced-practice paramedic. Greg is also a member of the Wake County EMS Tactical Paramedic team. 

Gary E. Linder, MSPA, NREMT-P, APP, is an advanced-practice paramedic with Wake County EMS. He has over 25 years of experience in EMS education, management and leadership. He served in the U.S. Naval Reserves as a SAR corpsman/rescue swimmer and officer in the Medical Service Corps. He is the current AHA national faculty for ACLS in North Carolina.

Michael Lyons, BS, EMT-P, has worked in EMS over 17 years, and currently serves as a district chief for advanced-practice paramedics in Wake County EMS.

Lisa McDougall, AAS, EMT-P, has worked in the Wake County EMS system for over 12 years. She graduated from the original advanced-practice paramedic academy in 2008 and has served full time in the position since. Lisa has been instructing EMS through local community colleges for the last six years. She is currently working on her BS in emergency medical care.

B. Daniel Nayman, BS, NREMT-P, has been active in the Wake County EMS system for over 10 years and currently works as an advanced-practice paramedic. He has completed graduate-level courses in public health, public administration and healthcare administration, and has recently completed the coursework toward his MBA.