Southwest Texas Crisis Collaborative

Just about anyone who has worked in health care longer than a few days is familiar with the issues related to caring for mental health patients.  Yet, for as long as most of us can remember, we’ve been handling these patients the same way.

Law enforcement usually has the initial contact on emergency scenes.  Since the patients typically aren’t guilty of any crimes, they are handed off to EMS.  And because EMS does what EMS does, the patients are transported to a hospital emergency department and assessed. Once medically cleared – in other words, determined that there is no medical condition causing the signs and symptoms – the patient waits in the ED until a psychiatric bed can be found.

This practice, although common, causes problems on many levels:

  • It can tie up an EMS unit needlessly.
  • Hospital ED beds can be tied up for hours or even days until an appropriate receiving facility can be located. Data collected by the Southwest Texas Regional Advisory Council (STRAC) indicated most mental health patients were in the ED over nine hours per episode, and many much longer.
  • Most EDs are not equipped for mental health patients or long-term stays. Because these patients often require close monitoring or one-on-one care, the demands on staff are tremendous, resulting in a significant delay in mental health patients receiving the proper care.

All of this comes at a great cost.

Southwest Texas Regional Advisory Council (STRAC), headed by Executive Director Eric Epley, recognized the burden this practice was putting on hospitals and EMS agencies and how it was adversely affecting patients.  With the help of its very engaged hospital members, STRAC was able to determine that in 2015, approximately 3,500 mental health patients cost area hospitals $175 million.  At times, local EDs had half their beds tied up with mental health patients, for whom they could provide only limited care.  STRAC concluded that for all the expense, the system was helping precious few patients.

A better way

With input from stakeholders, collectively referred to as the Southwest Texas Crisis Collaborative, STRAC developed the Law Enforcement Navigation Program for emergency detention patients. The collaborative included all member health systems, Methodist Health Care Ministries, the local Mental Health Authority, City and County Government, the San Antonio Police Department and the Bexar County Sheriff’s Office, San Antonio Fire Department, UT Health OMD, and Acadian Ambulance, all mental health facilities in the area, and other philanthropic and non-profit groups. Methodist Health Care Ministries stepped up and provided the initial funding that finally got the program underway; with continued financial commitment from the local health systems, the city, the county, and the San Antonio Area Foundation.

The program’s premise is simple: Take patients where they can get the most appropriate care.  But, of course, nothing is ever quite that easy.

Protocols had to be developed and approved by medical directors of the hospitals and EMS agencies.  Attorneys had to be satisfied about the risk to each agency and organization.  The process had to be closely monitored to make sure this helped patients. Throughout the process, STRAC provided guidance and continues to be heavily involved.

The process

When law enforcement arrives to find a patient they believe to have a mental health problem – one who they have no reason to suspect has ingested drugs or suffered trauma and who does not complain of medical issues or give any impression that a medical evaluation is needed — the officer may transport the patient to a psychiatric facility.  STRAC provides direction on facility choice through its MEDCOM, which serves as a 24-hour dispatching entity.  The officer calls MEDCOM for navigation to the closest, most appropriate psychiatric facility, which allows MEDCOM to load balance the entire system, limited impact to any one behavioral health hospital and providing expedited unloading for the police officer.

If the officer feels uncertain about the patient’s condition or would prefer to have a medical opinion, EMS is dispatched to assess the patient.  Using a strict set of protocols and involvement from medical directors, EMS may clear the patient to be transported by the law enforcement agency or may determine the patient does, in fact, require evaluation and treatment at a hospital ED. Then EMS transports to a hospital ED.

Has it worked?

According to STRAC Division Director Sarah Hogan, who oversees this innovative program, it is working, and working well.  Mental health ED visits have been reduced by 50%, saving hospitals a great deal of cost.  Over 9300 patients were redirected in 2018 and now the program redirects over 900 patients per month to more appropriate care. ED staff spends less time monitoring mental health patients, freeing the staff to care for other patients; and EMS units spend less time responding to mental health calls. However, beyond the savings in money and time, the overwhelming benefit is that these patients are receiving the care they need much sooner and at the type of facility that will benefit them the most.