Mobile Crisis Centers: A Solution for Behavioral Health Access

00:00:00:15 - 00:00:35:29
Tom Haederle
Hospital admission rates for people who come to the emergency department are much higher if that person is also dealing with a behavioral health condition. But many patients with behavioral health issues don't necessarily need to be admitted as an inpatient. It may not be the best course of treatment for them, and it also costs much more. That's why Maryland-based Sheppard Pratt has been road testing mobile behavioral health services, and the experiment is paying off.

00:00:36:01 - 00:01:12:22
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Two clinicians and a vehicle. That's the model Sheppard Pratt uses as its behavioral health experts have begun to visit patients in their homes or other places that don't require a visit to the hospital. In this podcast, Jordan Steiger, senior program manager of Clinical Affairs and Workforce with the AHA, is in discussion with Jason Melegari, director of clinical services at Sheppard Pratt, about how its mobile Behavioral Health Initiative continues to make a positive difference for the people and communities it serves.

00:01:12:25 - 00:01:14:15
Tom Haederle
Let's join Jordan.

00:01:14:17 - 00:01:23:20
Jordan Steiger
Jason, thank you so much for joining us this morning at the AHA Leadership Summit. We're so happy to have you here and to learn a little bit more about some of the work you're doing.

00:01:23:22 - 00:01:25:04
Jason Melegari, R.N.
It's a pleasure. Thank you Jordan.

00:01:25:06 - 00:01:33:22
Jordan Steiger
Great. So I know that you work at our member hospital, Sheppard Pratt in Maryland. Tell the listeners a little bit about your role and what you do.

00:01:33:25 - 00:02:03:03
Jason Melegari, R.N.
Sure. I am part of the consulting arm of Shepherd Pratt. I'm director of clinical services, so I provide subject matter expertise when it relates to really anything clinical. But I think my areas of real passion are issues related to regulatory concerns, accreditation, but also clinical programing, training, education, workforce development, as well as just general health care operations.

00:02:03:05 - 00:02:19:09
Jordan Steiger
So all of those things that kind of touch behavioral health and touch other parts of health care too. But those are the big ones there. So I know that one of the things that you've worked on lately is bringing mobile crisis services to communities around you as part of your consulting role. Is that right?

00:02:19:12 - 00:02:51:04
Jason Melegari, R.N.
Certainly that's something that we are really trying to build and get people on board with crisis services, because you can only add so many more beds to a community. And oftentimes we find that communities have kind of over bedded. When we look at admission rates to behavioral health hospitals, sometimes you can compared it - if we were to admit every patient that walked into an emergency department with chest pain.

00:02:51:07 - 00:03:11:02
Jason Melegari, R.N.
Now the rates of admission there, that's around 12 to 17%, whereas sometimes we're admitting upwards of 50 to 80% of folks that come into an ED with a behavioral health concern. Or even come in with some other concern, and it ends up being a behavioral health admission.

00:03:11:03 - 00:03:11:25
Jordan Steiger
Absolutely.

00:03:11:26 - 00:03:39:22
Jason Melegari, R.N.
So in order to kind of grab those before they come in, one could probably reduce admission rates by 25%. And a big part of that is mobile crisis, where you're bringing the talents of those clinicians to the individual. And I think that I'm very passionate about crisis service. A crisis service doesn't always just have to encompass behavioral health because it's a crisis.

00:03:39:22 - 00:04:01:14
Jason Melegari, R.N.
And it doesn't have to necessarily be a behavioral health crisis. But mobile crisis clinicians are trained in dealing with a variety of issues. I don't want to compare it to a home health type of experience, but it is bringing that care to the home, to an organization, it's just wherever the crisis is happening.

00:04:01:14 - 00:04:08:21
Jordan Steiger
Just in that community space, wherever somebody needs help, you're sending those clinicians out to them instead of them coming to the hospital.

00:04:08:27 - 00:04:43:16
Jason Melegari, R.N.
Exactly. You know, and sometimes it does result in a need for that individual to get further care, but it doesn't have to be in a hospital. I think that trying to find things like Shepherd Pratt does, like urgent care spaces or crisis residential services, where folks can be in a controlled environment for 1 to 4 weeks. It depends on the situation, but I think the biggest problem facing the crisis is a issue of reimbursement.

00:04:43:18 - 00:04:47:17
Jordan Steiger
That was going to be one of my questions. Yes. How do we pay for this?

00:04:47:20 - 00:05:04:02
Jason Melegari, R.N.
Well, there are states that are getting on board with paying for that, and it's mostly through Medicaid type of programs or grant funding. But we all know that that's kind of unsustainable for a long period of time.

00:05:04:02 - 00:05:04:22
Jordan Steiger
Definitely.

00:05:04:26 - 00:05:31:02
Jason Melegari, R.N.
And, you know, while the Medicaid population certainly has a large proportion of folks that are in need, there's lots of us that have commercial insurances that aren't recognizing these crisis episodes either. So oftentimes and those just go unfunded because certainly we're not going to care for them. We're going to provide that service. But yeah. Is it an issue of sustainability.

00:05:31:05 - 00:05:35:12
Jason Melegari, R.N.
And that does affect how we're going to develop that workforce too.

00:05:35:16 - 00:05:45:18
Jordan Steiger
Absolutely. So would you encourage listeners to maybe look at their state regulations and reimburse kind of policies and see if this is something they could do in their own communities?

00:05:45:26 - 00:05:58:02
Jason Melegari, R.N.
I think people really need to advocate, whether it be through city, county, states or federal organizations, to talk about how this, you know, this actually saves money.

00:05:58:05 - 00:05:58:29
Jordan Steiger
Absolutely.

00:05:59:03 - 00:06:31:10
Jason Melegari, R.N.
You know, a one time say, three-hour interaction with an individual, let's just say it's $1,000. Whereas going to the ED, usually, I think the American College of Emergency Physicians says a behavioral health episode in an ED cost nearly $2,500. Plus then the ensuing admission, which might be to be very conservative, $1,000 a day for 4 to 5 days.

00:06:31:13 - 00:06:40:09
Jason Melegari, R.N.
So with it is a considerable savings and the individual in crisis gets to possibly resolve that crisis in a friendlier environment.

00:06:40:15 - 00:06:57:21
Jordan Steiger
And, you know, divert that admission, which I know is a good thing for the patient. It's good for their support system, and it's good for our hospitals, too, if we don't need to have people sitting in the ED waiting for behavioral health care. And, you know, we know that that has become such a thing that people are trying to figure out.

00:06:57:23 - 00:07:21:23
Jason Melegari, R.N.
Absolutely. And, you know, just the environment in the ED is not conducive to a behavioral health claim in any way. And often it has that iatrogenic effect of making them more anxious and then just that fact leading to admission just because they're there. And maybe they were only seeking help to get a prescription refill or school or something like that, that all of that happens with those clients.

00:07:21:24 - 00:07:31:22
Jordan Steiger
Exactly, exactly. So walk me through what a typical patient interaction would look like. Say somebody calls the their crisis number in their community. What happens next?

00:07:31:24 - 00:08:02:17
Jason Melegari, R.N.
So let's assume from a mobile crisis standpoint, sure. A team of clinicians or you know, I think one of the more exciting things is to have peers also interact in that. So generally you'd want two people and the models that we're trying to create have a peer involved and a clinician that doesn't have to be necessarily a licensed clinician depending on the state and or reimburse guidelines, but then going to meet that individual.

00:08:02:20 - 00:08:39:00
Jason Melegari, R.N.
Sometimes there is a law enforcement portion of that. Sometimes they initiate that. But let's say that they didn't. And then just really finding out what that crisis is, trying to find support systems that may be already there or helping them to make a safety plan, call people, seeing if there's a way to get there, if they have a physician involvement or a therapist involved in their treatment, seeing if they can also be involved in that interaction in some way doesn't have to necessarily be in person.

00:08:39:05 - 00:09:02:11
Jason Melegari, R.N.
Sure. But really trying to find connections. That's what really is the most important part, is the connection. When you lack connection, then without that support, oftentimes it tends to start rolling downhill, but helping them build the connections, whether they're there or not. It's one of the most important things a mobile crisis clinician can do.

00:09:02:13 - 00:09:22:03
Jordan Steiger
That makes a lot of sense. And just making sure that that patient or that person just really gets to the place that they need to be in, whether it's seeing their PCP or seeing their psychiatrist or maybe they don't need anything, maybe they just needed somebody to talk to in that moment and they're okay. So having that moment just to say, what do you actually need, I think is so important.

00:09:22:06 - 00:09:43:04
Jason Melegari, R.N.
Yeah, I think one of the better stories I've heard in this is from, I think a crisis team in Pennsylvania is that they were called to a crisis. And it was a working mother that had 3 or 4 children and had a long day at work. And her crisis was that she didn't have anything to feed her kids dinner.

00:09:43:06 - 00:10:07:18
Jason Melegari, R.N.
Crisis was easily solved by the team. It ordered pizza for the family, and who knows what that would have led to possibly in an hour or 2 or 3. But that was that person's crisis. And again, we don't have to look at it necessarily all the time from a behavioral health standpoint. But we know that crises often develop into that.

00:10:07:21 - 00:10:29:15
Jordan Steiger
Absolutely. I think that's a great example to share. To show that to somebody doesn't have to be in, you know, a psychiatric episode to need a service like this. It could be something as simple as needing to feed their kids. So I think that's a beautiful example to share. One thing you brought up was the use of peer supporters, and I think that that is something that we all need to start exploring in behavioral health a little bit more.

00:10:29:20 - 00:10:41:22
Jordan Steiger
So I just wanted to flag that as we were talking. That stuck out to me, and I'm sure stuck out to some of our listeners, because we know that peers are just able to connect in a way that's different than a clinician or other people a lot of the time.

00:10:41:24 - 00:11:17:00
Jason Melegari, R.N.
Absolutely. You know, having that shared experience is crucial. And I find that peers are often able to defuse crises situations so much better than those of us that don't have that shared experience. Also, recovery coaches, certainly in that realm as well. And I think that in many settings, especially emergency departments, they are able to divert patients in a way and to find them the services they need in a much more efficient manner.

00:11:17:03 - 00:11:38:21
Jordan Steiger
Absolutely. So you're really making the case here for mobile crisis service and support. So I'm hearing you say that it's a cost diversion. We can keep people out of the ED and out of inpatient care, especially when they might not necessarily need that level of care. We're hearing that we can address some of those social drivers of health which we know affect health overall.

00:11:38:21 - 00:11:51:20
Jordan Steiger
So I mean, I think the case is there for communities investing in this. What advice would you give maybe a new hospital system or community that's looking to develop their mobile crisis services?

00:11:51:22 - 00:12:19:15
Jason Melegari, R.N.
My plan for folks that don't have any, and this is kind of more related to the hospital system. So great. What I suggest is you know, because it's very low overhead, you need two clinicians and a vehicle. Oftentimes, I suggest that those folks can even be based in your emergency department. And when they're not seeing folks in the community, they could help see people in the emergency department.

00:12:19:17 - 00:12:49:02
Jason Melegari, R.N.
So starting it could be, you know, a very easy task. It's really recruiting the right people for it is probably the hardest part of it. And then just slowly building that up, finding what area that you're going to serve. Make it small. And as your clinicians get more comfortable with it, increase that. Maybe you're just going to do it between - if you're in that health system - maybe you're going to do it between your hospitals or even PCP offices.

00:12:49:05 - 00:13:09:18
Jason Melegari, R.N.
So there's lots of, I think, innovative ways to do it that serve your system first as well as your community then. Usually I would say that starting slow on perhaps in the afternoon and hours is where I think that or finding out when your behavior.

00:13:09:18 - 00:13:10:29
Jordan Steiger
When the need is the highest.

00:13:10:29 - 00:13:18:05
Jason Melegari, R.N.
Yeah, exactly. And then expanding it further. Don't start out with a 24 hour service because you're going to stumble and fall.

00:13:18:05 - 00:13:32:25
Jordan Steiger
Sounds overwhelming to start, definitely! That's good advice. I think starting small and just focusing on the need of your hospital system and then kind of letting that overflow into what is the need of your community and kind of connecting those dots, it sounds like.

00:13:32:28 - 00:13:37:01
Jason Melegari, R.N.
During this time, you're going to have to explore the reimbursement process.

00:13:37:02 - 00:13:37:20
Jordan Steiger
Definitely.

00:13:37:20 - 00:13:55:09
Jason Melegari, R.N.
So if you're looking how you can just serve your health system, you are going to save system dollars whether or not you're going to be reimbursed. So I think that's the smart way to begin, at least for a health system. For a community, yes, it's going to take a little more because you're going to have to look for grants.

00:13:55:09 - 00:14:10:22
Jason Melegari, R.N.
But they are plenty out there and some are reimbursing very well after you are accepted for that RFP or however, the community is doing it. But for a hospital system, I think that you could start right away.

00:14:10:24 - 00:14:22:18
Jordan Steiger
That sounds like a call to action if I've ever heard one. So Jason, thank you so much for joining us and sharing a little bit more. Are there any places that you would recommend people looking if they're wanting more information about this?

00:14:22:20 - 00:14:39:21
Jason Melegari, R.N.
Certainly there is a crisis...SAMHSA and I think that just looking for other communities in hospitals that are already utilizing the service and just asking them questions. I find that I do that a lot and I find that they're very open.

00:14:39:23 - 00:14:46:11
Jordan Steiger
Awesome. Well, thank you again for joining us, and I'm looking forward to having this information shared with our membership.

00:14:46:14 - 00:14:48:21
Jason Melegari, R.N.
Thank you very much, Jordan, I appreciate it.

00:14:48:23 - 00:14:57:03
Tom Haederle
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