The Agency for HealthCare Research and Quality (AHRQ) released an eye-opening study this past week, indicating that utilization of emergency department (ED) services due to behavioral health conditions increased sharply from 2006 to 2013. The brief “Trends in Emergency Department Visits Involving Mental and Substance Use Disorders,” highlights a 52 percent increase in ED utilization by people experiencing a serious mental illness, and a 55.5 percent increase for other behavioral health conditions, such as anxiety, depression, or stress reactions. Even more significant is that these increases were largest in lowest income communities, causing the percentage of behavioral health-related ED visits covered by Medicaid to increase, while the percentage of visits covered by private insurance actually decreased. Because the time period of the report predates states’ expansion of Medicaid under the ACA, the report may signal a trend that policymakers, particularly in non-expansion states, will want to examine further. The report offers insights for states that are already working on these challenges, and affirms states’ multi-pronged efforts to prevent behavioral health crises using diverse, integrated approaches.
Reducing ED utilization has been a key goal for state health reform efforts, often with a focus on addressing behavioral health problems “upstream” through improved access and integration strategies. Some of the state strategies that have documented positive results include the following:
Improving communication and follow up at the ED: In Washington, a partnership of doctors, hospitals and state Medicaid representatives collaborates on the “ER is for Emergencies” initiative to reduce avoidable ED visits. This initiative developed the “Seven Best Practices Program” approach to address the needs of people who are frequent ED utilizers and also have multiple chronic conditions, substance use disorders, and lack of primary care access. The program tracks ED visits through an Emergency Department Information Exchange (EDIE) and tracks patients’ prescribed controlled substances through the state’s Prescription Monitoring Program (PMP), while collaboratively working to ensure visits with primary care physicians within 72 hours. A March 2014 report released by the Washington State Health Care Authority showed a 9.9 percent decline in emergency department visits, and a 10.7 percent decline of super-utilizers.
- Linkages to community resources and emergency responders: Delaware developed a Crisis Intervention Service (CIS) model to prevent unnecessary or inappropriate hospitalizations of people experiencing mental health symptoms or substance use disorders. The state contracts with teams of nurses and a variety of behavioral health professionals to provide screening, assessment, treatment, and referral for people in crisis. In addition, crisis staff works with every police department throughout the state to provide training for police academies and evaluation assistance for people with criminal charges. Crisis centers have seen diversion rates from emergency departments as high as 80 percent.
- Creating shared accountability and integrated networks: Oregon’s coordinated care organizations (CCOs) model is an integrated network of all types of health care providers (physical, mental, dental) focused on prevention and management of chronic conditions for Oregon’s Medicaid population. Under this model, the Oregon Health Authority holds four percent of monthly payments to CCOs, which are put into a ‘quality pool.’ To earn full incentive payments, CCOs need to meet benchmarks or improvement targets on at least 12 of the 17 incentive measures, including ED utilization, and have at least 60 percent of their members enrolled in a patient-centered primary care home. A 2015 report of the CCO model showed an 18 percent reduction in ED utilization and a seven percent reduction in avoidable ED utilization.
These examples show a range of state delivery system reforms that can be used to target ED utilization, both for people with very serious behavioral health conditions, and those who may be able manage these disorders within primary care. AHRQ’s new research underscores the importance of engaging multiple sectors of the health care system to address behavioral health needs, and may provide additional insights for state policy makers on how to address these complex policy issues.