Health systems are seeing a steep increase in patients coming to emergency departments (EDs) for psychiatric conditions.
However, the ED is often not the best place for patients in a psychiatric crisis. One major ramification of this increase is many of these patients can face a long wait time, causing a significant bottleneck in the ED.
As a response, many health systems have invested in creating an alternative type of emergency psychiatric care, called EmPATH units, which specifically cater to caring for patients with behavioral health conditions.
“Over the last decade, the number of behavioral emergency patients in [emergency rooms] has increased over 400%. And now one in every seven patients in the ER is there for behavioral emergencies,” Dr. Scott Zeller, the founder of the EmPATH model and VP of acute psychiatry at Vituity, told Behavioral Health Business. “What ends up happening is that these poor folks who are having maybe the worst day of their lives are getting stuck in the ER for a very long time – hours, days and in some cases, even weeks, waiting for an elusive inpatient bed to open up.”
Vituity is a physician-owned and led health care delivery organization. Its services include emergency medicine, outpatient care, hospital medicine, psychiatry, neurology and telehealth.
In response to the crisis, Zeller developed the first de novo EmPATH unit in 2016, but the model has since gained steam across the country.
California, Virginia, Pennsylvania, Minnesota, South Carolina and Iowa all have an EmPATH unit or are creating one.
What is an EmPaTH?
At its core, EmPATHs, which stand for environment, emergency psychiatry assessment, treatment and healing, is an alternative to an ED for patients presenting with psychiatric conditions. It is set up to better serve and observe behavioral health patients for up to 24 hours.
EmPATHs look different from a traditional ED because they are designed to provide a calming environment catering to behavioral health patients’ needs.
“The idea is that all negative stimuli in the emergency department are toned down, and it’s more sensory sensitive,” Stephen Parker, a behavioral health planner at Stantec, told BHB. “You can have a reclining chair and your own dedicated space for calming. … You don’t have all this bustle going back and forth. It’s supposed to be a much more calming, therapeutic experience. Patients can access things that you normally wouldn’t get in an emergency room, such as a sensory room, a quiet room, a nutrition space so they can get themselves a snack and food.”
Stantec is an architectural, construction management engineering firm headquartered in Edmonton, Canada.
EmPATHs can be within an ED, adjacent to an ED, or somewhere else on the hospital campus, according to the 2022 Facility Guidelines Institute. Patients typically still go through the ED but can be quickly referred to an EmPATH unit when medical conditions are stabilized or ruled out.
“One of the great things about EmPATHs is that by meeting all these needs quickly, it helps to reduce a lot of the things that cause people to become frustrated, agitated,” Zeller said. “Our staff are well trained in de-escalation. And we have spaces on EmPATH units called calming rooms where somebody can go and chill out if they are starting to escalate.”
EmPATHs are typically staffed with nurses and behavioral health-specific clinicians, including social workers and psychiatrists. Some units also have peer support specialists to help guide patients and connect them to resources, according to Zeller.
More appropriate care
Inpatient mental health care is not only restrictive for a patient but also costly. The average cost of an inpatient mental health hospital stay at non-profit hospitals was $2,653 per day, according to Psych U.
Still, due to the nature of the ED, many patients in crisis are referred to inpatient care.
“When an emergency department sees a patient in crisis, they do a brief assessment, sometimes in the height of the crisis,” Lewis Zeidner, M Health Fairview’s system director for clinical triage and transition services, told BHB. “And they make a risk-based judgment about what they need. And so they’re going to skew towards keeping them safe appropriately.”
M Health Fairview is a partnership between the University of Minnesota, University of Minnesota Physicians and Fairview Health Services. The health system includes 10 hospitals and 60 clinics.
Zeidner noted that before implementing an EmPATH unit at the health system’s Southdale facility, about 45% of patients coming to their ED for a mental health or substance use disorder crisis were hospitalized.
EmPATH units have time and expertise that could help curb the ED-to-inpatient pipeline for many patients.
“We see people over time. And we can see them both in that most desperate moment when they first come in, but over 24 to 48 hours,” Zeidner said. “Often, we’re able to de-escalate the crisis. They’re able to regain some of their agency as an adult and get back to a higher level of functioning closer to what they were functioning before the crisis, whatever triggered that. And so we can serve them on more outpatient bases without hospitalization and [the patients can] retain their agency as adults. There’s less trauma of an outpatient service often than an inpatient hospitalization.”
Southdale’s EmPATH unit now reports that it hospitalizes about 18% of the patients who come into the unit.
More appropriate care can also lead to better patient and care team relationships. For example, Zeller noted that patient restraints are used much less in EmPATH units than in traditional EDs.
“If we’re not having a lot of these unfortunate folks being tied down and restraints and having meds forcibly injected into them and all those things that are scary and understandably so,” Zeller said, “maybe there’ll be more interested in working with folks voluntarily and not waiting until it’s too late – and ending up in that coercive situation.”
Patients treated in an EmPATH unit were also less likely to return to ED than patients treated in a traditional emergency room.
Additionally, patients treated in an EmPATH unit were more likely to get follow-up care.
A study published in Academic Emergency Medicine reported a 60% increase in 30-day follow-up care for patients treated in EmPATH units.
“Our goal is to turn our emergency patient into an outpatient and make them feel more like a part of the system and not that their mental health system is their adversaries,” Zeller said, “but rather they’re colleagues and collaborators.”