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The American Journal of Managed Care December 2018
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Feasibility of Expanded Emergency Department Screening for Behavioral Health Problems
Mamata Kene, MD, MPH; Christopher Miller Rosales, MS; Sabrina Wood, MS; Adina S. Rauchwerger, MPH; David R. Vinson, MD; and Stacy A. Sterling, DrPH, MSW
Risk Adjusting Medicare Advantage Star Ratings for Socioeconomic Status
Margaret E. O’Kane, MHA, President, National Committee for Quality Assurance
Reducing Disparities Requires Multiple Strategies
Melony E. Sorbero, PhD, MS, MPH; Susan M. Paddock, PhD; and Cheryl L. Damberg, PhD
Cost Variation and Savings Opportunities in the Oncology Care Model
James Baumgardner, PhD; Ahva Shahabi, PhD; Christopher Zacker, RPh, PhD; and Darius Lakdawalla, PhD
Patient Attribution: Why the Method Matters
Rozalina G. McCoy, MD, MS; Kari S. Bunkers, MD; Priya Ramar, MPH; Sarah K. Meier, PhD; Lorelle L. Benetti, BA; Robert E. Nesse, MD; and James M. Naessens, ScD, MPH
Patient Experience During a Large Primary Care Practice Transformation Initiative
Kaylyn E. Swankoski, MA; Deborah N. Peikes, PhD, MPA; Nikkilyn Morrison, MPPA; John J. Holland, BS; Nancy Duda, PhD; Nancy A. Clusen, MS; Timothy J. Day, MSPH; and Randall S. Brown, PhD
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Feasibility of Expanded Emergency Department Screening for Behavioral Health Problems

Mamata Kene, MD, MPH; Christopher Miller Rosales, MS; Sabrina Wood, MS; Adina S. Rauchwerger, MPH; David R. Vinson, MD; and Stacy A. Sterling, DrPH, MSW
This feasibility study of expanded emergency department screening identified a high prevalence of behavioral health conditions. Screening was successfully integrated into emergency visit idle times.

Objectives: Behavioral health conditions and social problems are common yet underrecognized among emergency department (ED) patients. Traditionally, ED-based behavioral health screening is limited. We evaluated the feasibility of expanded behavioral health screening by a trained nonclinician.

Study Design: Prospective observational study of a convenience sample of ED patients.

Methods: A research assistant (RA) approached a convenience sample of adult ED patients within an integrated healthcare delivery system. Patients completed a paper screening instrument (domains: mood, anxiety, alcohol use, drug use, sleep, intimate partner violence, and chronic pain) and reviewed responses with the RA, who shared positive screening results with the treating ED physician. We abstracted behavioral health and medical diagnoses from the electronic health record (EHR), comparing the screened cohort with the eligible population. We used χ2 tests to assess differences in demographics and comorbidities between screened patients and the eligible group and differences between self-reported symptoms and EHR diagnoses among screened patients.

Results: Among 598 screened patients, the prevalence of self-reported symptoms was higher than that of associated EHR diagnoses in the year prior to the ED visit (anxiety, 45% vs 19% [P <.001]; depression, 40% vs 22% [P <.001]; drug use, 7% vs 4% [P = .011]; risky alcohol use, 12% vs 5% [P <.001]; chronic pain, 47% vs 30% [P <.001]; and sleep problems, 47% vs 4% [P <.001]).

Conclusions: A dedicated RA was able to integrate screening into patient idle times in the ED visit. The prevalence of behavioral health problems was higher than indicated in the EHR.

Am J Manag Care. 2018;24(12):585-591
Takeaway Points

Behavioral health problems (depression, anxiety, and alcohol and drug misuse) are common yet underrecognized in emergency department (ED) patients. These conditions contribute to other health conditions, such as diabetes and hypertension, but if they are undiagnosed, they go untreated. Improving our detection of these conditions can accelerate referral to and initiation of treatment and improve downstream health outcomes and costs.
  • Leveraging a nonclinician to perform screening in the ED was successful and nonintrusive.
  • The prevalence of behavioral health conditions was higher than identified in the electronic health record.
  • Further studies linking screening to pathways for referral to treatment and assessing quality outcomes would be helpful.
Research findings suggest that behavioral health conditions such as depression, anxiety, and alcohol and drug misuse, as well as intimate partner violence (IPV), are common among emergency department (ED) patients1,2 and that their prevalence is higher than typically noted by ED physicians and staff.3-5 These conditions are a source of considerable morbidity (eg, disability-adjusted life-years lost due to depression/anxiety), are associated with other common health conditions and poorer health outcomes, and can drive healthcare utilization and costs.6-9 Although effective interventions for these conditions exist, identification is essential to providing patients with appropriate referral and treatment.

Historically, widespread screening among ED patients has been limited to acute risk for suicide and IPV. However, the typical ED visit is interspersed with periods of idle time during which patients wait for test results, re-evaluation by clinicians, and treatment effects. These intervals create opportunities for screening, brief interventions, and referrals to treatment or other resources.

Previous behavioral health screening pilot implementation studies in the ED have focused primarily on alcohol and drug abuse and suggest feasibility, albeit with concerns about workload for ED providers and intervention fidelity.5,10-14 The screening instruments used in US-based studies were lengthy, and the pilot periods were short (1 week). A brief screening instrument that covers several key domains has not been tested in the ED setting. Furthermore, IPV, chronic pain, and sleep problems are important contributors to depression, anxiety, and alcohol and drug use.15-19 Screening, intervention, and referral for these conditions in ambulatory care settings such as primary care has increased detection and treatment initiation rates.20,21 However, patients may miss opportunities for screening and referral to treatment if their main point of contact with health services is the ED.

This study examined the feasibility of introducing screening for common behavioral health problems in the ED setting using an embedded research assistant (RA) and a brief screening instrument. We also examined the rates of documented diagnoses compared with self-reported problems covered in the screener among patients presenting for ED services in an integrated healthcare system.



Kaiser Permanente Northern California (KPNC) is a nonprofit integrated healthcare delivery system providing comprehensive healthcare services to more than 4 million members in northern California. KPNC provides integrated medical and specialty psychiatric and chemical dependency treatment within the health system. Members are racially and socioeconomically diverse and representative of the regional population.22 The study ED is the site of 65,000 annual visits and is staffed by more than 60 full-time board-certified or board-eligible physicians and 220 nurses.

Study Population

KPNC members 18 years or older with no health plan enrollment gaps of greater than 3 months in the year prior to their index ED visit (during the study period, October 10, 2015, to June 12, 2016) were eligible to participate. Patients were initially eligible if they presented with non–life-threatening and nonminor complaints and were defined as having an Emergency Severity Index (ESI) score of 2 or 3. The ESI calculator is a commonly used triage algorithm for stratification based on acuity and predicted resource needs that grades patients from level 1 (most urgent) to level 5 (least resource intensive).23 Patients who were seen in the “fast-track” area of the ED for minor complaints (ESI score of 4 or 5) were considered ineligible because their length of stay was typically too short to allow for screening without interrupting workflow.

Over the study period, an RA approached ED patients who met eligibility criteria in their treatment rooms, 5 evenings per week (Monday through Friday), from approximately 3 pm to 10 pm. Patients verbally consented to participate and completed a paper screening tool covering the following domains: depression, anxiety, alcohol use, drug use, sleep, IPV, and chronic pain. The RA reviewed the screener with patients for clarity and confirmed affirmative responses. The RA also suggested to patients that they discuss positive results with their care team. The ED attending physician was notified of positive screening results, and the care team addressed the identified concerns based on clinical judgment.

This screening pilot was supplemental to currently practiced screening for IPV and emergent psychiatric conditions, which were separate from the study protocol. Current ED practice for addressing IPV and emergent psychiatric conditions includes consultation with psychiatry and mental health, as well as social work referral. Because the screener conditions did not require emergent intervention and because our study was designed to assess screening feasibility, we did not have mandated referral pathways but instead relied on patient–clinician and RA–clinician communication for next steps.

Because the RA was in the ED only during limited hours, our screened cohort comprised a convenience sample of eligible patients during the study period. Our RAs did not document patients who declined to participate, so the cohort consists of only those patients who agreed to participate.

Feasibility of the proposed screening intervention was assessed during the prestudy period through qualitative discussions with ED physicians, nursing staff, social workers, administrative staff, and behavioral health leadership. We observed ED clinical workflow in relation to screening activities to ensure minimal disruption of the ED visit. We also identified treatment team members with whom the RA would communicate before approaching patients to confirm that the screening activity would not delay treatment.

The study was approved by the KPNC Institutional Review Board.

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