Citation

Blonigen DM, Manfredi L, Heinz A, Bi X, Suarez P, Nevedal AL, Vashi AA, Timko C, Wagner T. Psychiatr. Serv. 2018; 69(4): 438-447.

Affiliation

Apart from Dr. Bi, the authors are with the Center for Innovation to Implementation, U.S. Department of Veterans Affairs (VA) Palo Alto Health Care System, Palo Alto, California. Dr. Blonigen, Ms. Suarez, Dr. Vashi, Dr. Timko, and Dr. Wagner are also with the Stanford University School of Medicine, where Dr. Blonigen and Dr. Timko are with the Department of Psychiatry and Behavioral Sciences, Ms. Suarez is with the Department of Neurosurgery, Dr. Vashi is with the Department of Emergency Medicine, and Dr. Wagner is with the Department of Surgery. Dr. Heinz is also with the National Center for PTSD, VA Palo Alto Health Care System. Dr. Bi is with Anthem, Inc., San Jose, California.

Copyright

(Copyright © 2018, American Psychiatric Association)

DOI

10.1176/appi.ps.201700288

PMID

29385959

Abstract

OBJECTIVE: Use of psychiatric emergency services in emergency departments (EDs) and inpatient psychiatry units contributes substantially to the cost of mental health care. Among patients who utilize psychiatric emergency services, a small percentage ("high utilizers") contributes a disproportionate share of the total cost, yet little is known about the context of care for these patients. This study employed qualitative methods to identify barriers to and facilitators of reducing use of psychiatric emergency services among high utilizers.

METHODS: Semistructured phone interviews were conducted with 31 directors of mental health services and providers of psychiatric emergency services across 22 Veterans Health Administration medical centers. The Consolidated Framework for Implementation Research was used to guide the interviews to evaluate the context of care for high utilizers. Thematic coding was used to identify barriers to and facilitators of reducing utilization.

RESULTS: Barriers emerged at the patient level (for example, treatment nonadherence and transiency), provider level (for example, stigma toward high utilizers and lack of expertise and training in the management of psychiatric issues among ED staff), and system level (for example, lack of specialized services to address short- and long-term care needs). Facilitators included recovery-oriented care; interdisciplinary care coordination and case management, with emphasis on the role of psychiatric social workers; and predictive analytics to flag high utilizers.

CONCLUSIONS: The findings lay the groundwork for the design of novel approaches to care for high utilizers of psychiatric emergency services while limiting provider burnout, managing costs, and optimizing treatment outcomes.

Language: en

Keywords

Emergency psychiatry, Homelessness, Utilization patterns & review, Veterans issues