The ROI of telePsychiatry in the ED

Hospital Information

Allen Hospital is a 204-bed not-for- profit community hospital located in Waterloo, Iowa. The hospital cares for more inpatients, outpatients, emergency and cardiac patients than any other in its 10-county service area. Allen is affiliated with UnityPoint Health, which cares for one out of every three patients in Iowa and is the state’s largest health system.

In 2018, Allen added telePsychiatry services to its emergency department, in response to strained behavioral health resources and a growing population of patients with mental health needs. The result was a domino effect that reduced length of stay, improved throughput in the emergency department, and created an annual ROI for the hospital of 281%.

Executive Summary

  • Boarding of behavioral health patients fell steeply, as did average length of stay (ALOS)
  • ALOS for mental health patients decreased by 11.87 hours
  • Reduced the admission rate by 4%
  • Avoided more than $1.7 million in annualized boarding costs and saw an annual return on investment of 281%
  • Both the patient and provider satisfaction has improved

The Challenge

In 2017, Allen Hospital was facing an increasingly difficult challenge caring for behavioral health patients. The hospital has a 21-bed inpatient behavioral health unit and one full-time psychiatrist. In the surrounding community there was often a 3-month wait for an outpatient psychiatric visit—thus many patients turned to the hospital for care. The demand for psychiatric evaluations was continually overloading the hospital’s resources.

In the emergency department (ED), where the problem was at its most acute, patients who required mental health evaluations faced extended wait times. Like many community hospitals throughout the country which face similar challenges, these patients were often boarded in hallways, or scattered in rooms throughout the ED while they awaited evaluations.

Increased wait times meant patient dispositions were not being met in a timely manner. The lack of resources and specialized psychiatric expertise led to longer boarding times thus increasing patient agitation.

“From our perspective, it was very chaotic,” said Nick Rosauer, a mental health counselor at Allen. “Behavioral health patients were spread across the emergency room. Patients’ psychiatric needs weren’t being met, and it would lead to agitation and irritability, and rightfully so.”

The hospital’s resources were also stretched thin on the inpatient side. Allen had one locum psychiatrist and additional locums were repeatedly burning out. The psychiatrists often could not get around the hospital for all the consults necessary within 24 hours.

There were other issues. Allen Hospital’s behavioral health unit does not see adolescents. Placing those younger patients at other facilities in the community drew additional time from clinical staff and away from other patients in the ER.

Hospital leadership knew that Allen had to make a change.

The Solution

Allen’s solution was three-pronged:

  1. A new investment in on-site behavioral health consultants and psychiatric safety techs.
  2. A physical reorganization of the ED.
  3. A partnership with SOC Telemed to provide both emergency and inpatient telePsychiatry consults.

First, Allen formed a behavioral health response team, comprised of behavioral health consultants and psychiatric safety techs. One behavioral health consultant is staffed in the ED 12 hours/ day, focused primarily on disposition of ED patients. Safety techs are staffed 24/7 and are tasked with meeting the needs of the psychiatric patient while ensuring their safety.

“If anyone presents with a behavioral health need, we do the initial assessment and determine whether further action is needed from a psychiatrist or a medication manager,” Rosauer said. “We are kind of like the caretakers to mental health; we set a plan of care moving forward.”

Next, the hospital reorganized the space in the ED, sectioning off one hallway and its adjoining rooms to serve as an emergent behavioral health unit. The new unit includes five rooms, all ligature-free, and a crisis observation area.

Finally, to close the gap on the shortage of clinical resources, Allen partnered with SOC Telemed to provide telePsychiatry consults, both in the emergency department and most recently in their med surge units.

SOC began providing on-demand 24/7 telePsychiatry coverage in January 2018. The combination of access to SOC’s board-certified psychiatrists, the reorganized emergency department, and new onsite mental health counselors initiated a domino-effect of positive results for Allen Hospital, its staff, and its patients.

The Solution

The results were first felt in the emergency department. With the new space devoted to behavioral health and the addition of more staffing, boarding of behavioral health patients fell steeply, as did their average length of stay (ALOS).

An analysis by SOC and UnityPoint Allen showed dramatic results:

  1. When comparing the 12 months prior to beginning telePsychiatry service to the 21 months following, ALOS for mental health patients fell 11.87 hours.
  2. At an average cost to the hospital of $62 per boarding hour, Allen avoided more than $1.7 million in annualized boarding costs.
  3. Taking into account the investment in the SOC program over that same time period, Allen Hospital saw an annual return on investment of 281% based on reduction in boarding patients alone.

Both the patient and provider experience is also much improved.

With ready access to SOC’s specialists, ED throughput improved overall. With the hospital’s emergency physicians and nurses now more available to focus on other patients, average length of stay for the emergency department as a whole decreased by 66 minutes.

According to Rosauer, Allen’s ED physicians and nurses love the new program, in which a telePsychiatrist can assess suicide risk (according to the Columbia Suicide Severity Rating Scale) and help make the determination as to whether patients need to be admitted or discharged. Behavioral health patient satisfaction has increased, because those patients are getting seen far faster.

“We now have total buy-in from the providers,” Rosauer said. “They’re so comfortable with the new system that it would be hard to ever get rid of it.”

The effects are also being felt outside of the emergency department. The changes reduced the admission rate by 4%, and the time it takes to do consults has plunged dramatically, down to 2-3 hours per day. And with SOC assisting with night and weekend coverage, the hospital faces less burnout from its onsite clinical resources.

“Initially there were fears of the challenges we would face when implementing a new program including the associated costs, but then you see the analytics and the throughput and the quickness of certain things and the downhill revenue — the return on investment is just huge,” Rosauer concluded.