Reimagining Acute Behavioral Health

The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022

Reimaging Acute Behavioral Health Using Operational Studies to Improve Healthcare Facility Planning and Design for Behavioral Health in the Emergency Department Sabah Mohammed & Marvina Williams

University of Virginia University Hospital Emergency Department Expansion, Charlottesville, NC, Perkins&Will

The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022

Contents Introduction Methodology LEAN Planning Case Studies Recommendations Best Practices

University of Virginia University Hospital Emergency Department Expansion, Charlottesville, NC, Perkins&Will

The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022

Learner Objectives • Identify the challenges in delivering care for patients with behavioral health needs • Understand the financial impact of implementing behavioral health rooms in the ED, crisis units and EmPATH units • Describe innovative approaches in facility design and operational planning to improve the quality of care in the ED

University of Virginia University Hospital Emergency Department Expansion, Charlottesville, NC, Perkins&Will

The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022

Introduction Adults in the U.S. who live with a behavioral health (BH) disorder [1]

57%

70

182k Adults who died from alcohol and drug-related deaths in 2018, now termed as “deaths of despair” [3]

64.9

60 52.9 Visit rates per 1,000 people

20%

Emergency Department visit rates for adults with mental health disorders, by age group: U.S. 2017-2019

47.5

50 40

34.9

30 20 10

Adults with a BH condition who did not receive treatment [2]

0

All adults

18-44

45-64

65 and over

Age Groups Source: National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 2017–2019

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But this is not an adult problem alone.

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Adolescent BH statistics 13%

60%

Adolescents in the U.S. report having a major depressive episode, a 60% increase from 2007 [4]

Increase in suicide rates in 2018, from a stable rate between 2000-2007 [5]

Emergency department visits for self-harm by children and adolescents rose sharply over the last decade, particularly among young women

Emergency department visits for self-inflicted injuries Ages 10-19

Source: Centers for Disease Control and Prevention

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This has caught our collective attention.

The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022

988The Crisis Hotline

988

The 988 hotline is the national suicide prevention and mental health crisis hotline that went live on July 16th, 2022.

For BH patients, this means lesser interface with law enforcement agents and higher touchpoints with mental health professionals specially trained to respond to a crisis; and mobile crisis units.

For healthcare facilities, this means a higher volume of patients with high acuity in the Emergency Department (ED).

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Implications of 988 • 80% of the call volume can be resolved over the phone without dispatching mobile crisis teams, law enforcement, or emergency medical services.

• The remaining 20% represents a patient population that requires extremely high acuity care.

• This will overwhelm health systems, particularly Emergency Departments.

Source: Adapted from Cantor, J. H., Holliday, S. B., McBain, R. K., Matthews, S., Bialas, A., Eberhart, N. K., & Breslau, J. (2022). Preparedness for 988 Throughout the United States.

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Comprehensive Continuum of Care

Source: Adapted from Cantor, J. H., Holliday, S. B., McBain, R. K., Matthews, S., Bialas, A., Eberhart, N. K., & Breslau, J. (2022). Preparedness for 988 Throughout the United States.

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The ED 1 in 8

44%

ED visits are BH related issue [6]

Increase in BH related ED visits from 2018-2021 [8]

38%

17%

Increase in length of stay for BH patients [7]

Emergency physicians report a psychiatrist on call to respond to emergencies in the ED [9]

UTHealth Houston John S. Dunn Behavioral Sciences Center, Houston, Texas, Perkins&Will

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Cost

Quality

$2,265

38%

Additional cost per psychiatric ED stay [10]

BH patients in ED wait more than 7 hours to see a dedicated professional [12]

2 out of 5

$280B

65%

Psychiatric emergency patients or families who rated their ED experience as “bad” or “very bad”[14]

Spending on BH services in 2020, 5.5% of total health care spending [11]

BH patients experienced a medication error during ED stay [13]

Satisfaction scores

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“The emergency department is the last place you want to be when you are having a panic attack. You have nowhere to go and no one to take care of you.”

- ED Behavioral Health Patient

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The role of the built environment Design is a critical leverage point for healthcare systems. Architects and facility planners play a pivotal role in destigmatizing behavioral health.

Facility design can considerably impact the quality and effectiveness of BH treatment and plays a key role in recovery for many patients.

Providers cannot underestimate the importance of comfortable and secure facilities in achieving population health goals.

UTHealth Houston John S. Dunn Behavioral Sciences Center, Houston, Texas, Perkins&Will

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Research-Informed Design

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Methodology

65+

13

6

Literature reviews Peerreviewed journal articles & industry reports

Interviews with clinicians (6), architects (4), and BH patients (3)

Case studies of projects done by P&W (3), and externally (3)

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Understanding the constructs

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Understanding the outcomes

Impact vs Investment of Interventions Understanding the level of investment required as a function of the associated impact will guide architects and healthcare planners to meaningfully engage in client conversations.

DEGREE OF PSYCHO-SOCIAL SUPPORT Impact

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Equip ED with on-demand BH expertise

Dedicate care environments tailored to BH needs

Establish a Comprehensive Continuum of Care Continuum of care services

ED-based telepsychiatry

Designing for social support

Wrap-around clinics

Triage and stabilization

Harm reduction follow-ups

Investment CARE MANAGEMENT INTENSITY

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Healing design The five core tenets for healing design [15] Space flexibility Access to nature Calming interior design Positive distractions Clear lines of sight University ofUniversity Virginia University Hospital Emergency Source: The of Texas Health Science CenterDepartment at Houston,Expansion, Perkins&Will Charlottesville, NC, Perkins&Will

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Environmental Safety-Risk Assessment

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Environmental Safety-Risk Assessment Safety

Privacy

Although there is tension between safety and privacy, there does not need to be a tradeoff.

Spaces should be designed to be acuity- adaptable and adaptable for different patient populations.

Actively Suicidal Self harm not anticipated

Environmental Safety-Risk Assessment

INTENT FOR SELF -HARM (SAFETY)

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Level 2

Level 4

Level 1

Level 3

1:1 Observation

Periodic Observation

Completely alone

OPPORTUNITY FOR SELF-HARM (PRIVACY) Level 5: Special Considerations Source: Adapted from Hunt, J. M., Sine, D. M., DrBE, C. S. P., & ARM, C. (2018).

Behavioral health design guide.

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Lean Operational Planning in Design It brings together multidisciplinary teams in the development of processes, designing services and layouts responsive to the needs of the BH patient and staff by improving quality, safety, and delivery Designs are evaluated based on• Patient Experience • Staff Experience • Seven Flows of Healthcare • Operational Efficiencies • Flexibility • Infrastructure

Source: Duke University Medical Center, Perkins&Will

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Lean Operational Planning in Design Lean methodology can involve several steps: • • • • • • • • •

“Going to the Gemba” or place of work Create existing state process maps Evaluate the wastes Create ideal state process maps Create future state process maps focused on improving processes.

Gaming Boards (Kit of Parts) Create Design Options Continuously evaluating the 7 Flows of Healthcare VR and Built Mock-ups

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Seven Flows of Healthcare FLOW OF PATIENTS FLOW OF FAMILY FLOW OF STAFF FLOW OF SUPPLIES FLOW OF MEDICATION FLOW OF INFORMATION FLOW OF EQUIPMENT

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Critical Decisions Entrances & Triage areas Central vs. dedicated BH entrance

Location of BH rooms Part of main ED vs. ED module

Privacy Open bays vs. private rooms

Type of rooms Flex vs dedicated BH rooms

Team Station Open vs Closed

Safety Locked units vs. open connectivity

University of Virginia University Hospital Emergency Department Expansion, Charlottesville, NC, Perkins&Will

The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022

Critical Decisions Operationalized

Duke Behavioral Health Center North Durham, Durham, North Carolina, Perkins&Will

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De-escalation Room

Tift Regional Medical Center. Tifton, Georgia, Perkins&Will

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Flex roomGarage door

Cone Health Moses Cone Hospital North Tower, Greensboro, North Carolina, Perkins&Will

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Case Study 1

University of Virginia University Hospital Emergency Department Expansion, Charlottesville, NC, Perkins&Will

The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022

“As we wrap up the night shift, and the sun begins to come up, it feels like the mood of the entire ED lightens. That window, the daylight, and the views outside bring a sense of newness to the day and everyone’s mood just picks up a little.”

Dr. John Riordan, UVA Associate Professor of Emergency Medicine Vice-Chair of Clinical Operations

University of Virginia University Hospital Emergency Department Expansion, Charlottesville, NC, Perkins&Will

The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022

Wellness rooms adaptable for staff needs; equipped with undercounter refrigerator for nursing mothers

Above; Medical University of South Carolina Shawn Jenkins Children’s Hospital and Pearl Tourville Women’s Pavilion, Charleston, SC, Perkins&Will

Source: Virginia, Charlottesville, Perkins&Will Far leftUniversity and above:ofUniversity of Virginia University Hospital Emergency Department Expansion, Charlottesville, NC, Perkins&Will

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Case Study 2

Northside Hospital Gwinnett, Lawrenceville, GA, Perkins&Will

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Case Study 3

Medical University of South Carolina Shawn Jenkins Children’s Hospital and Pearl Tourville Women’s Pavilion, Charleston, SC, Perkins&Will

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Communicating Planning Concepts

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EmPATH Units • Stands for “Emergency Psychiatric Assessment, Treatment & Healing unit,” modeled on empathetic, rather than coercive, care.

• It is a hospital-based outpatient program that accepts all medically-appropriate patients in a psychiatric crisis, including involuntary psychiatric detention.

• Disposition decisions are not made until after a thorough psychiatric evaluation, treatment, and an observation period in the unit.

Outcomes 70%

25%

Reduction in LOS from 16.2 hours to 4.9 hours

Reduction in 30-day psych recidivism to ED

60%

$861k

Improved outpatient follow-up of patients from 39.4% t0 63.2%

Added to hospital’s ED bottom-line by moving psych patients that increased beds for non-psych patients.

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Recommendations & Best Practices

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Recommendations Barriers to optimal BH Care • Space constraints limit BH-specific room construction

Design Characteristics • Turn one or more patient pods into swing rooms to flex to current needs

• ED spaces are constricting and chaotic with little to no access to daylight or views

• Incorporate windows, murals, or posters to provide patients access to nature & light

• Non-BH patients feel uncomfortable in BH-outfitted rooms • Traditional ED rooms are safety hazards and make staff supervision difficult • ED spaces exacerbate BH conditions

• Use calming interior design to create BH rooms comfortable for all patients • Establish clear lines of sight with an open nursing station • Design a separate space with positive distractions to promote self de-escalation

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Best Practices • Crisis unit should be readily accessible to the ED • Clinical workflows tailored to needs of BH patients • Open design where patients can have privacy & move freely; while being safe, anti-ligature FFE • Safe, supervised environment with staff presence • Empathetic, whole person care vs. coercive care • Acuity-adaptable spaces • Minimize use of restraints; sedation; medication

Duke Medical Pavilion, Durham, North Carolina, Perkins&Will

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The Value of Design Environmental Variables

BH Value Stream Type of Practice Payment Matrix SDOH* Clinical Use Case

Clinical Outcomes, Quality and Safety

Access to Care

Patient, Family and Caregiver Experience

Clinician Experience

Financial and Operational Impact

Care Modality Health Equity *SDOH- Social Determinants of Health Source: Adapted from Care, T. D. E. (2022). Opportunities and Challenges.

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As we move the needle on the mental health crisis, designers play a critical role in shaping the built environment and ultimately, the human experience.

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Thank you!

Questions?

Memorial Sloan Kettering Monmouth Ambulatory Care Center, Middletown, New Jersey, Perkins&Will

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References 1.

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11.

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Alegria, M., Jackson, J. S., Kessler, R. C., & Takeuchi, D. (2007). Collaborative psychiatric epidemiology surveys (CPES), 2001-2003 [United States]. Ann Arbor, MI: Inter-university Consortium for Political and Social Research. https://www.icpsr.umich.edu/web/ICPSR/studies/20240 American Psychiatric Association, & American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA. Andrilla, C. H. A., Larson, E. H., Patterson, D. G., & Garberson, L. A. (2017, June). Supply and Distribution of the Behavioral Health Workforce in Rural America. In 2017 Annual Research Meeting. AcademyHealth.

Balfour, M. E., Hahn Stephenson, A., Delany-Brumsey, A., Winsky, J., & Goldman, M. L. (2021). Cops, clinicians, or both? Collaborative approaches to responding to behavioral health emergencies. Psychiatric Services, appi-ps.

Bastiampillai, T., Sharfstein, S. S., & Allison, S. (2016). Increase in US suicide rates and the critical decline in psychiatric beds. Jama, 316(24), 2591-2592.

Beck, A. J., Manderscheid, R. W., & Buerhaus, P. (2018). The future of the behavioral health workforce: optimism and opportunity. American journal of preventive medicine, 54(6), S187-S189.

Bentley, T. G., Effros, R. M., Palar, K., & Keeler, E. B. (2008). Waste in the US health care system: a conceptual framework. The Milbank Quarterly, 86(4), 629-659.

Billings, J., Parikh, N., & Mijanovich, T. (2000). Emergency department use in New York City: a substitute for primary care? Issue Brief (Commonwealth Fund), (433), 1-5.

Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: results from the 2014 National Survey on Drug Use and Health. HHS Publication No. SMA 15-4927, NSDUH Series H-50. Retrieved from https://www.samhsa.gov/data/ Chow, J. C. C., Jaffee, K., & Snowden, L. (2003). Racial/ethnic disparities in the use of mental health services in poverty areas. American journal of public health, 93(5), 792-797.

Chowdhury, S. M. S., Wun, L., & Machlin, S. (2012). Linking medical expenditure panel survey to the National health interview survey: weighting and estimation. Agency for Healthcare Research and Quality Working Paper, (12005).

Coster, J. E., Turner, J. K., Bradbury, D., & Cantrell, A. (2017). Why do people choose emergency and urgent care services? A rapid review utilizing a systematic literature search and narrative synthesis. Academic emergency medicine, 24(9), 1137-1149.

Garfield, R., & Young, K. (2015). Adults who remained uninsured at the end of 2014. Washington, DC: Kaiser Family Foundation.

Gindi, R. M., Black, L. I., & Cohen, R. A. (2016). Reasons for emergency room use among US adults aged 18-64: national health interview survey, 2013 and 2014. National health statistics reports, (90), 1-16.

Holland, K. M., Jones, C., Vivolo-Kantor, A. M., Idaikkadar, N., Zwald, M., Hoots, B., ... & Houry, D. (2021). Trends in US emergency department visits for mental health, overdose, and violence outcomes before and during the COVID-19 pandemic. JAMA psychiatry, 78(4), 372-379.

Hsia, R. Y., & Niedzwiecki, M. (2017). Avoidable emergency department visits: a starting point. International Journal for Quality in Health Care, 29(5), 642-645.

LaCalle, E., & Rabin, E. (2010). Frequent users of emergency departments: the myths, the data, and the policy implications. Annals of emergency medicine, 56(1), 42-48.

Marcozzi, D., Carr, B., Liferidge, A., Baehr, N., & Browne, B. (2018). Trends in the contribution of emergency departments to the provision of hospital-associated health care in the USA. International Journal of Health Services, 48(2), 267-288.

McCance-Katz, E. F. (2020). SAMHSA: creating a system of care that meets the needs of people with mental and substance use disorders. Psychiatric services, 71(5), 416-418.

Meyer, H. & Jaredson, S.R. (2017). Behavioral Health: Fixing a System in Crisis. Modern Healthcare. Retrieved November 26, 2021, from https://www.modernhealthcare.com/reports/behavioral-health/ Moore, B. J., Stocks, C., & Owens, P. L. (2017). Trends in emergency department visits, 2006–2014. HCUP statistical brief, 227.

Morley, C., Unwin, M., Peterson, G. M., Stankovich, J., & Kinsman, L. (2018). Emergency department crowding: a systematic review of causes, consequences and solutions. PloS one, 13(8), e0203316.

Nicks, B. A., & Manthey, D. M. (2012). The impact of psychiatric patient boarding in emergency departments. Emergency medicine international, 2012.

Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health & Human Services. Trends in the Utilization of Emergency Department Services, 2009-2018. 2021. https://aspe.hhs.gov/pdf-report/utilization-emergency-department-services Parwani V, Tinloy B, Ulrich A, D'Onofrio G, Goldenberg M, Rothenberg C, Patel A, Venkatesh AK. Opening of Psychiatric Observation Unit Eases Boarding Crisis. Acad Emerg Med. 2018 Apr;25(4):456-460. doi: 10.1111/acem.13369. Epub 2018 Feb 1. PMID: 29266537.

Peth, H. A. (2004). The emergency medical treatment and active labor act (EMTALA): guidelines for compliance. Emergency Medicine Clinics, 22(1), 225-240.

Pitts, S. R., Niska, W., & Burt, C. W. (2008). National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. National health statistics reports; no 7.