The changing landscape of health care during COVID-19 placed focus on increasing accessibility to mental health resources other than the emergency department (ED), with potential savings of over $4 billion in annual costs and improvements in patient outcomes.
Emergency department (ED) visits by patients who access care for mental health or substance abuse–related issues that could have been treated in another setting are often referred to as “avoidable” ED visits.
These preventable, or avoidable, ED visits place a strain on ED capacity and have high costs—an estimated $8.3 billion per year, according to a 2019 analysis by Premier.1 However, the term “avoidable ED visits” places the onus of these effects on patients, when the issue is much larger, explained one expert.
Interventions to improve patient access to mental health care and expand available resources can reduce avoidable ED visits, cut costs, and improve patient health outcomes by following the principle of meeting patients where they are.
Going to the ED for Mental Health
There are a multitude of reasons that account for why patients face barriers to accessing mental health care, and those reasons are not reflected in the language often used to describe the problem.
“The term ‘avoidable ED visits’ suggests that there is an appropriate and alternative place to care for people who have medical needs,” Renee Hsia, MD, MSci, professor of emergency medicine and health policy at the University of California at San Francisco, wrote in an email exchange with The American Journal of Managed Care®. “Often patients are portrayed as the problem, when really the problem is that the resources they need are not easily available to them, so there is a failure in the system.”
Avoidable ED visits occur for a variety of reasons related to health insurance and access. Patients may use EDs for mental health due underinsurance or uninsurance, or inadequate access to in-network mental health providers. Going to the ED in a mental health crisis is an option only because EDs are required to stabilize all patients regardless of their ability to pay, under the Emergency Medical Treatment & Labor Act.2
EDs may also be more accessible than other forms of care, such as primary or preventive forms of care. When primary care facilities are not open on nights or weekends or have long wait times, they are not accessible.2
Costs of Avoidable ED Visits and Impact on Patients
According to a study published in the Journal of Clinical Psychiatry, between 2007 and 2016, about 8.4 million (8.3%) of 100.9 million ED visits nationwide were for psychiatric or substance use-related diagnoses.4
The $8.3 billion spent each year on ED care represents an increase from $4.4 billion in 2010 annual costs for unnecessary ED visits, according to a study published in Health Affairs.3 Eliminating unnecessary ED use for mental illness could save about $4.6 billion annually, the Premier report indicates.1
Patients not only incur significant costs from ED use, but they also experience poorer outcomes and reduced quality of care. The CDC reports that patients with mental health disorders experienced more ED visits lasting 4 hours or longer compared with patients without mental health disorders.
In a 2016 study, Hsia found that length of stay was significantly longer for psychiatric patients who were discharged, admitted for observation, or transferred to another facility, compared with nonpsychiatric patients with similar dispositions.5
“We do know that patients with psychiatric conditions tend to wait longer in the ED for treatment,” she wrote. “This is not good for them, obviously, and also not good for other patients who use the ED, since it means we have fewer resources (eg, rooms, nurses, doctors) for others seeking care in the ED.”
Psychiatric visits also ended in disproportionately higher transfer rates than nonpsychiatric visits, with wait times for transfer increasing over the study period from 2002 to 2011.5
“ED visits in and of themselves are not a problem. We have EDs to help patients with life and limb-threatening conditions, and to be a source of emergency medical care,” added Hsia. “There are some conditions that are better treated in other settings, and our healthcare system needs to be incentivized to make these settings more available to patients.”
The pandemic highlighted the drastic need for additional resources for mental health.
In an email exchange about ED use during the COVID-19 pandemic, Kristin Holland, PhD, MPH, chief of the Surveillance Branch of the CDC, Division of Violence Prevention, explained that EDs are a common place for people to seek care. Mental health and suicide-related incidents are acute in nature and require immediate care, which means many patients seek care in the ED for these conditions.
“Another reason people may have visited EDs for these kinds of incidents at the beginning of the pandemic could be that resources that were typically available to the public—eg, school counselors, behavioral health clinics, primary care offices—may have been closed because of stay-at-home orders and other COVID-19 mitigation efforts,” she added.
Holland conducted a study on ED visits for mental health, overdose, and violence outcomes before and during the COVID-19 pandemic. According to the findings, ED visits actually began to decline at the beginning of the pandemic after nationwide stay-at-home orders were implemented.6
Holland and her colleagues found that ED visits for mental health, suicide attempts, and also intimate partner violence declined to a lesser extent than ED visits overall during the early weeks of the pandemic.6
ED visit rates also for mental health conditions were found to be significantly higher in 2020 compared with 2019, with stark increases in rates for mental health–related ED visits observed beginning in Week 13, coinciding with the implementation of nationwide stay-at-home-orders.6
Mental health–related ED visit rates remained greater than prepandemic rates throughout the entire study period.
Holland noted that while COVID-19 mitigation efforts such as avoiding crowds and social distancing were necessary, they made people feel isolated and lonely. In addition, financial hardship and job losses experienced during the pandemic can contribute to worse mental health.
In addition to exacerbating mental health issues, the pandemic also further limited the resources available to patients and people delayed or avoided medical care because they wanted to avoid risk of exposure to COVID-19, she said.
“While schools, businesses, and other resources eventually did open back up, some resources never fully rebounded and were permanently closed,” Holland wrote. “Further, many state- and federally staffed public health resources had to shift focus during the pandemic to address more immediate concerns about the spread of COVID-19, limiting services they could provide in the mental health space.”
Interventions to Mitigate Unnecessary Use of the ER
HHS has suggested that that additional behavioral health and SUD treatment resources to improve access to existing resources may be needed to help reduce “avoidable” ER visits among people with mental health or substance use disorders.2 Various intervention strategies have been implemented in health care systems, communities, and at state and federal levels.
Interventions to support triage for patients and increase capacity and access to care in non-emergency settings could improve patient outcomes while reducing cost.
One such intervention model is The Living Room, a crisis diversion center in Schenectady, New York.
The Living Room, offered by Ellis Medicine in partnership with CDPHP, is an outpatient program that offers crisis stabilization and acts as an ED alternative for patients.7 CDPHP is a physician-founded and -guided health plan based in Albany, New York, and The Living Room is located in the metropolitan area surrounding Albany.
The program serves an under-resourced and underserved population who need mental health providers and services. The facility serves CDPHP members, health plans in the area, as well as uninsured patients.7
“The way The Living Room works is that someone, if they're in a crisis or if they have an issue or a problem, they can actually just walk in on a drop-in basis and talk to counselors,” said Vanessa Bobb MD, PhD, CHIE, VP, BH and Medical Integration, CDPHP, in an interview. “There are social workers, there are care managers, care specialists, where they can be evaluated and assessed.”
According to Bobb, evaluation and stabilization at The Living Room costs an average of $200 compared to the average cost of $1300 for an ED evaluation.
The Living Room also offers the benefit its name conveys: a better environment for patients with mental health needs.
“There are couches, there’s soft lighting—it’s more conversational. It’s a much more relaxing place—more relaxing, less intensity than you would have in the emergency room,” says Bobb.
Patients have reported decreases of their distress and anxiety levels of approximately 30% when accessing The Living Room during a crisis.7
The program offers therapists and care managers on-site that can offer help with social determinants of health, which the HHS note as concerns for communities that exhibit high reliance on hospitals for psychiatric services.
Since the program opened in 2018, The Living Room has served over 3200 patients, resulting in a cost savings of nearly $4 million in unnecessary ED visits. During the first 4 months of 2022, $960,000 in ED diversions were seen among the patient population, which is largely comprised of Medicaid or Medicare members.7
To prevent ED visits, The Living Room focuses on prevention. Patients are encouraged to connect with their primary care providers. For CDPHP members, there is a call center that can help triage, assess patients in crisis, and direct them to appropriate resources. Patients who go to The Living Room can access support directly from the licensed master-level social workers, care managers, and peer counselors on staff.7
Though the goal of The Living Room is ED diversion, Bobb still suggests patients use the ED when necessary: “Depending on what’s going on, if that person is in acute danger to themselves or someone else, often the best place to go would be the emergency room.”
The success of The Living Room in Schenectady has inspired the introduction of a second living room model in Rensselaer County, another county near Albany. Living Room models are also being implemented in states across the country.
State and Federal Interventions
Though digital and technology-based resources have been available for mental health patients for years, the COVID-19 pandemic brought the use of technology in mental health care to the forefront.
HHS reported that the share of Medicare visits conducted through telehealth in 2020 increased 63-fold, from approximately 840,000 in 2019 to 52.7 million. Despite COVID-19 cases waning, the use of telehealth has remained at a high level.
The flexibility of telehealth may eliminate barriers to care, which is why expanding access to telehealth and virtual mental health care options is one of the priorities of the White House’s strategy to address the country's mental health crisis. Other interventions could include expanding community behavioral services, integrating mental health treatment into primary care settings, and increasing behavioral health navigation resources.
On July 16, a nationwide 3-digit dialing code launched for Mental Health Crisis and Suicide Prevention. The 988 code connects callers to the existing National Suicide Prevention Lifeline.
In some states, such as New Jersey, mobile crisis response units and crisis receiving and stabilization resources are being developed to supplement the existing mental health care resources. Additionally, many states are expanding ambulatory care and paramedicine in an attempt to reduce costly use of ED resources.
“There’s a continued need for widespread mental health, suicide, overdose, and violence prevention efforts and for continued surveillance so we can understand where to direct the limited resources we have to implement prevention efforts,” Holland noted.
If you’re in crisis and need support, please call or text 988 or chat with the 988 Suicide & Crisis Lifeline at 988lifeline.org/chat. Veterans can call 988 and press 1.