By Anne Millington
The patient had been suffering from behavioral health and substance abuse issues, and the emergency department, although clearly not the right place for him, was where he was “boarding” now. But where could he go? The social worker and a case manager raised possibilities — an inpatient psych unit, a detox facility? But as the chaplain for the Care Integration Program, I had more information. I had asked the patient about his hopes, about what he was praying for, and he told me it was to move to a different city, where he currently had a very solid job opportunity waiting for him. As a result, the care integration team immediately pursued follow-up care options to ensure he could take this job and have professional support in his new city.
I have been honored to serve as a member of the Care Integration Program, an interdisciplinary group set up to serve the growing number of behavioral health patients arriving at the emergency department at Beth Israel Deaconess Hospital-Milton in Massachusetts. Behavioral health patients are frequently in serious crisis, maybe suffering from acute schizophrenia, manic depression, suicidal thoughts, drug and alcohol abuse, and many more complex issues that emergency departments are generally ill equipped to manage. Inpatient psychiatric facilities and other placement options may be limited, and with no other appropriate alternatives, behavioral health patients can well turn into emergency department “boarders,” having a prolonged stay — even up to 21 days and longer — in the emergency department, their only safe haven if no other option is available. This benefits no one, as behavioral health patients cannot receive the specialized care they need. Meanwhile, emergency departments become more crowded, and the overall environment becomes less conducive to care for everyone.
Funded by a $2.1 million grant from the state of Massachusetts’ Health Policy Commission, the BID-Milton care integration team consists of a nurse director, two social workers, a music therapist, a chaplain (me), an emergency department physician and nurses, a pharmacist, a security officer, as well as administrative and analytical support personnel. Behavioral health patients receive a bundle of services to reduce their risk of symptom escalation, including more timely crisis evaluation, insurance verification, and care transition management; therapeutic interventions (such as cognitive behavioral therapy), medication management, music therapy, faith counseling, peer services, familial counseling and support. The physician, nurses, and social workers meet regularly, and additional meetings also occur regularly for the whole C.I. team.
When a patient is discharged, the team develops a return care plan to expedite future treatment, ensuring patient and staff safety and facilitating timely patient access to behavioral health services. In addition, the team provides a “warm hand-off” to all receiving providers and follow-up by a community behavioral health navigator (a social worker who follows the patient into the community and helps him/her access services) and a peer worker (a person with “lived” experience with a behavioral health disorder). Through medical charting and additional technologies, C.I. team members coordinate to provide active and ongoing patient support. Members also get daily census reports and a real-time dashboard of core patient indicators. “Tiger Text” secure/encrypted texting ability enables us to provide timely clinical interventions and rapid interdisciplinary input.
As the chaplain, I encourage patients to reflect on their spirituality and its presence in their current circumstances. I focus on questions such as: What are their hopes? Their regrets? Their dreams? Where is God in their lives? If they do not believe in God, who or what brings meaning to their lives? In the time I have spent with behavioral health patients, I have come to appreciate how much spiritual healing is possible, even for patients whose reality is very troubling and even quite distorted. One woman was inconsolably upset that her boyfriend had just shot her ex-husband and her two children. But in reality, her boyfriend had not seen her in 10 years and had certainly not shot her ex-husband and children, who were very much alive and well and had taken a restraining order out against her. Even though her despair was not grounded in reality, I was able to bring some comfort and peace to her within the parameters of her world, mainly by entering that world and companioning her in her sadness and anger over losing these important family relationships, and permitting her feelings of abandonment.
Because I have no other agenda than to listen and explore, behavioral health patients have at times shared with me formerly uncovered facets of their lives and experiences that have made a critical difference in clinical outcomes. Also, I have become more visible and thus more integrated with health care teams throughout BID-Milton, and I have found that I receive more clinician requests to visit patients in every area of the hospital.
The care integration program has become a model for other programs seeking to offer integrated services to behavioral health patients. The program gives them quicker access to the clinical services they need, and emergency room service for other patients greatly improves. The program has reduced emergency department length of stay for “boarding” behavioral health patients, in spite of an increase in patient volume, a shortage of inpatient psychiatric beds, and a statewide opioid crisis. In 2016, its first year, the program achieved a 20% reduction of behavioral health patient length of stay, reversing what had been a 30% increase in 2015. This greatly improved emergency department accessibility; previously, behavioral health patients accounted for 1% of emergency department patient registrations yet consumed 11% of resources.
Going forward, the C.I. team will continue to provide organizational development and training for staff to manage behavioral health patients more safely and effectively. The program was recently implemented on the BID-Milton inpatient floors for certain medical and surgical patients who also have behavioral health conditions, and we will seek funding opportunities to expand the program to all complex patient populations.
I am truly honored to serve on the team, and I have great respect for my colleagues’ commitment to caring for behavioral health patients. Recently I complimented our C.I. director of care for her efforts to “help the hopeless.” She looked me straight in the eyes and quickly responded, “To me, no one is beyond hope.” Truly, people can and do recover, particularly with the compassionate commitment of clinicians who believe in them. As a Catholic, I see the care integration team exhibiting day in and day out the cherished values of Catholic social teaching, including a belief in universal human dignity, a preferential treatment for the poor and marginalized who are also the face of God in our world, and a fierce commitment to the common good.
Anne Millington is a chaplain at Beth Israel Deaconess Hospital in Milton, MA.
