And Emergency Services: Problems And Advantages
January 01, 2009
In large population centers there is a growing use of emergency
rooms, crisis centers, ERs, emerge-centers and crisis mental health triage centers to
handle urgent and emergency problems. Managed care organizations are contracting
with community mental health programs, HMOs, insurance companies and public health plans
to provide crisis services in large population centers. The main purpose of these
contracts is to pool resources and help insure there is an available and cost effective
place for police, ambulances, families and friends to take people during a mental health
crisis or psychological emergency.
General Advantages Of Using Community Crisis
- Centralized Access To Medical Evaluation And Hospitalization
Services. Emergency problems are probably the main reason why Crisis, ER's and
Triage Centers can be the best place to go. Services are available 24 hours a day.
The facilities have the ability to evaluate, stabilize, hold and transport people to
hospital, psychiatric and other evaluation facilities.
- The Ability To Restrain And Hold Patients. The ability
to evaluate and hold people against their will for evaluations regarding potential
dangerousness is a principle role of these centers. Most people are brought to these
centers by police or ambulance.
- Immediate Stabilization For Severe Problems.
Stabilization is the primary role of community crisis and emergency services. This
may involves education, providing information, problem solving, persuasion and
- Referral For Case Management And Follow-up Services.
The ability to provide follow-up services will vary with each ER, Emergi-Center and Crisis
Triage Center. Some have ongoing relationships with community mental health centers
which may contract with them. Some facilities are connected to their own managed
care organization and to other organizations.
Potential Problems When Using Community Crisis Services
While there has been significant progress in making some emergency
and crisis intervention services available, there are still serious problem areas.
Eight general problem areas are:
- Negative Experience. While they can be the best place to
go for extremely serious problems, the experience can feel strange to say the least,
if not devastating and humiliating. Many of these centers are overloaded,
understaffed, inexperienced, poorly trained and provide services to an extremely wide
range of clients that may include people who are restless, emotionally unstable,
irritable, acting strange or bizarre, or being held against their will by the
police. These settings are often busy and the sheer pressure of working with so many
highly distressed people can produce a degree of impatience or cynicism in some staff.
- People Usually Want To Leave. Convincing an adult or
youth go to voluntarily, to cooperate, and to stay long can be difficult. Many
people who go to an ER, Crisis Center or psychiatric hospital want to leave at once.
They may express a desire to leave once they get there, after they wait a while or after
they are admitted. The reasons are usually simple. The entire experience and
environment is stressful. It can be difficult or even impossible to hold a patient
who voluntarily checks into a crisis or emergency center if they change their
mind during or before the evaluation. To hold an adult there must be sufficient
evidence for a physician to hold the person. Many youth are able to act normally
once they arrive and can readily convince staff that serious problems described by parents
do not really exist.
- Gaps In Care. There are tremendous gaps between the
needs of the individual or family and the services offered by many managed care
organizations and public funded crisis services. Funding for these
services are often low in comparison to the demand and need. Crisis services are usually designed
to serve a community and to be reimbursable as much as possible by health insurance and managed care
companies. Still, each crisis or emergency is unique and may require individual
attention as well as a unique response to insure the best outcome.
- Rationing Services For Profit. Crisis and mental health
triage centers are increasingly run by businesses that make higher profits when fewer
services are provided. Services may be rationed using "invisible"
(unknown) and informal criteria driven by the organization's administrative and financial
goals. These criteria can override professional judgment and
recommendations. Services are often organized around traditional
services that include psychiatric hospitalization, residential treatment,
outpatient therapy or medications. The cost and impact of limiting
and denying necessary services can be as high as 30% of the total health
care cost. There is considerable argument that the cost of limiting
services exceeds the cost of the services denied in many cases.
- Emphasis on Emergencies. Crisis and mental health triage
centers focus primarily on emergencies that require immediate stabilization, symptom
management, medication or hospitalization. Crises and urgent problems, or problems
that are not considered immediate dangers are often minimized and given inadequate
follow-up care. Minimization of a crisis can have a negative impact if a critical
opportunity to intervene is lost. The outcome of a missed intervention can be a
diminished sense of importance and resistance to getting help in the future. When
people first acknowledge a crisis or ask for help, they may need comprehensive help.
- Inadequate Follow-Up Care. Referral to outside providers
from a crisis or triage center is an uncertain process and depends on
available county services, the insurance, as well as HMO
or manage care companies involved. In some cases there can be a complete lack of
coordination, a failure to forward essential information to the professional taking the
referral, and utter confusion when a crisis resurfaces before the first appointment. For
the most part, follow-up care is limited to that which is available
through country mental health services and authorized or provided by HMOs,
or insurance or managed care companies.
- Excessive Focus On The Patient. Unfortunately there are
many aspects to a crisis and many people are usually affected by a crisis. The
consequences of a single individual in a crisis can have a significant impact on friends,
families and loved one. These people are in distress as well and may also need
reassurance, praise, feedback and assistance to debrief their experience. Some will
need help developing plans to manage future problems or the possibility of acute
relapse. This level of support and service is generally not provided by hospital or
crisis center based services. Just because the services are not provided by
managed care, or insurance or an HMO does not mean the service is not needed, not critical
to resolve the crisis, or necessary to prevent future crises.
- Unclear Treatment And Intervention Standards. Depending
on the county you live in, your insurance, HMO or health care company, the benefits and the treatment you receive
can vary tremendously. As evidence by the debates in state and
federal government, it is a practice in many managed care,
insurance and HMOs to deny services that you may be entitled to and for
these organizations to compel
professionals to quietly support (or at least not protest) service delivery constraints
which are based primarily on economic considerations.