Specialized short term crisis intervention for patients with personality disorder: Effects on coercion and length of stay.

BACKGROUND: Acute crises in patients with personality disorders (PD) are often accompanied by suicidal and self-harming behavior. Their management is challenging, as both coercive measures and prolonged inpatient-treatment are known to be counterproductive. Only in crises that cannot be controlled by outpatient means, inpatient treatment is to be taken into account. This treatment should be time-limited and not involve coercion. AIMS: The aim of this study was to assess if the introduction of a specialized crisis intervention track is associated with a reduction of coercive measures as well as a shorter in-hospital stay in PD patients. METHODS: In this 8-year, hospital-wide, longitudinal, observational study, we investigated the frequency of coercive measures and the median length of in-hospital stay in 1,752 inpatient-cases with PD admitted to the Adult Psychiatry, UPK, Basel, Switzerland, between 01.01.2012 and 31.12.2019. By means of an interrupted-time-series analysis, we compared the period before and after the implementation of a specialized crisis intervention track for PD patients. RESULTS: Our data show a significant decrease in the median length of in-hospital stay and no significant reduction in the incidence rate of coercion among PD patients after the intervention. The latter is likely due to a floor effect, since there was a significant decrease in coercive measures over the entire observation period, already reaching very low rates before the intervention. CONCLUSIONS: Our study underlines the clinical importance of specialized short-term crisis management in PD, which comes along with shorter lengths of in-hospital stays and a stable low rate of coercive measure.

Acute Emotional Impact of Peer Suicide and Student-Related Factors.

OBJECTIVE: This study explored the negative emotional impact of peer suicide on adolescent students during the early stages of becoming aware of suicide and examined the adverse effects of related environmental and mental health factors. METHODS: This study was conducted from March 1, 2020 to December 31, 2021, targeting students enrolled in middle and high schools where student suicide occurred. Emotional impact was assessed using the Korean version of the Impact of Event Scale-Revised (IES-R-K), State-Trait Anxiety Inventory-X, Center for Epidemiologic Studies-Depression Scale (CES-D), and Beck's Scale for Suicide Ideation (SSI). χ2 test and Pearson's correlation analysis were performed to analyze subgroup differences and explore relationships between scale scores, respectively. RESULTS: Of the 2,382 participants, 25.1% belonged to the post-traumatic stress disorder (PTSD) or PTSD tendency group on the IES-R-K, and 22.2% showed abnormalities in the State-Trait Anxiety Inventory-State. Students in the same class as the deceased student and those in the same grade but in different classes had higher risk rates than those in different grades. Boarding school students had 1.9 times higher odds of experiencing emotional impacts than non-boarding students. On the CES-D, 10.4% of the students showed potential depression, with 3.7 times higher odds of experiencing emotional impact than those with normal scores. Moreover, 4.5% of the students reported suicidal ideation on the SSI, with those experiencing mild suicidal ideation having 1.9 times higher odds of experiencing emotional impact than those with normal scores. CONCLUSION: A significant proportion of students experienced negative impacts of peer suicide. Students in close-knit environments, such as the same class, grade, and boarding school as the deceased, or those with depression or anxiety experienced a more pronounced negative impact.

[Psychotherapeutic approaches to crises]. / Psychotherapeutischer Umgang mit Krisen.

BACKGROUND: Psychotherapeutic interventions play a crucial role in alleviating psychological distress and promoting resilience during personal and global crises. OBJECTIVE: What general principles are relevant for psychotherapeutic crisis interventions in acute psychiatry? What contributes to an in-depth understanding of individual reactions to the course of crises? When do global crises translate into personal crises? How can global crises be integrated into the psychotherapeutic process? MATERIAL AND METHODS: Selected results from the scientific literature on psychiatric psychotherapeutic crisis interventions in acute psychiatry are reviewed and summarized. RESULTS: Although the evidence for specific crisis intervention strategies in acute psychiatry is limited, general principles for psychotherapeutic crisis interventions can be derived. CONCLUSION: Understanding early relational experiences based on psychodynamic or learning theory processes influences the application of further crisis intervention techniques and their impact on affected individuals.

Assessing a Suicide Prevention Helpline's Impact on Caller Crisis Level and Suicidality.

OBJECTIVE: Worldwide helplines are considered an important part of suicide prevention strategies. Nevertheless, evidence regarding the impact of suicide prevention helplines on the suicidality of its users remains limited and is frequently confronted with methodological issues. This study aimed to assess the impact of crisis calls on callers' levels of crisis and suicidality both immediately after the call and at follow-up compared to before the call. After the call, the satisfaction of the callers with the intervention was also assessed. METHODS: A pre-post study, generated automatically by a telephone system, was conducted in order to compare the level of crisis and suicidality (operationalized by five indicators: hopelessness, entrapment, controllability, suicidal intent, and social support) experienced by callers before and immediately after the call and at follow-up (one to two weeks after the call). RESULTS: Callers (n = 487) showed significant improvement in their level of crisis (p < .001, d = -0.31), hopelessness (p < .001, d = -0.22), entrapment (p < .001, d = -0.25), suicide intent (p < .001, d = -0.37), and social support (p < .001, d = 0.33) after the call compared to before the call. Improvements were also found at follow-up compared to pretest. The satisfaction of callers with the helpline was high. CONCLUSIONS: This study adds to the growing evidence on suicide prevention helplines and addresses some important methodological issues in helpline research. Furthermore, it shows promising results regarding the potential supportive impact of helplines on callers who feel suicidal.

Crisis helpline research is limited and often confronted with methodological issuesCallers improve in experienced levels of crisis, hopelessness, entrapment, supportStudy shows potential of helplines to positively influence individuals in crisis.

Mental Health Crisis: An Evolutionary Concept Analysis.

The term 'mental health crisis' is a widely used concept in clinical practice and research, appearing prominently in mental health literature across healthcare and social science disciplines. Within these contexts, the term is frequently either left undefined or defined rather narrowly, confined to clinical observations or guidelines targeted at healthcare providers and negating the multifaceted nature of crisis as described by those with lived experience. Therefore, the aim of this paper is to explore the characteristics of and provide a conceptual definition for the concept of 'mental health crisis'. Rodgers' method of evolutionary concept analysis was employed and 34 articles, ranging from 1994 to 2021 and a variety of disciplines, were analysed. The results highlighted the contrast between clinically oriented surrogate terms and related concepts and those used by individuals with lived crisis experience. Antecedents of crisis included underlying vulnerabilities, relational dysfunction, collapse of life structure and struggles with activities of daily living. The concept's attributes encompassed the temporality of crisis, signs and symptoms of crisis, functional decline and crisis in family and caregivers. Finally, the consequences comprised looking inward for help, looking outward for help, and opportunities and dangers. This concept analysis serves as a foundational step in understanding 'mental health crisis' and its various dimensions, facilitating more nuanced discussions and interventions in the realm of mental healthcare.

Crisis Receiving and Stabilization Facilities: Designing Systems for High-Acuity Populations.

Crisis facilities provide a safe and therapeutic alternative to emergency departments and jails for people experiencing behavioral health emergencies. Program design should center around customer needs which include individuals and families in crisis and key community stakeholders like first responders. Ideally, a crisis system should be organized into a broad continuum of services that ensures care is provided in the least restrictive setting, even for people with high acuity needs, and stakeholders should have a clear understanding of the capabilities of each component facility and the population it can safely serve. This paper provides a framework to help policymakers achieve this goal.

Multidimensional Approaches to Quality Measurement and Performance Improvement in the Ideal Crisis System.

This work expands on the National Council for Mental Wellbeing whitepaper Quality Measurement in Crisis Services. The authors present 2 approaches to measure development: The first maps flow through the crisis continuum and defines metrics for each step of the process. The second uses the mnemonic ACCESS TO HELP to define system values, from the perspective of various stakeholders, with corresponding metrics. The article also includes case examples and discusses how metrics can align multiple components of a crisis system toward common goals, strategies for using metrics to drive quality improvement initiatives, and the complexities of measuring and interpreting data.

Community-Based Mental Health Crisis Response: An Overview of Models and Workforce Implications.

Communities across the United States are working to improve community-based mental health crisis response, with 1 goal being to reduce criminal legal system involvement among individuals with mental illnesses, behavioral disorders, or mental health crises. Existing and recently developed models can generally be divided into non-law enforcement-based response models and law enforcement-based response models. Wide variation exists in terms of staffing, how response teams are called out or dispatched, hours of operation and immediacy of response, and approaches to crisis resolution.

Characterizing Crisis Services Offered by Certified Community Behavioral Health Clinics: Results From a National Survey.

OBJECTIVE: The authors aimed to examine how certified community behavioral health clinics (CCBHCs) fulfill crisis service requirements and whether clinics added crisis services after becoming a CCBHC. METHODS: National survey data on CCBHC crisis services were paired with data on clinic features and the demographic and socioeconomic characteristics of the counties within a CCBHC service area. The dependent variables were whether CCBHCs provided the three categories of CCBHC crisis services (i.e., crisis call lines, mobile crisis response, and crisis stabilization) directly or through another organization and whether these services were added after becoming a CCBHC. Descriptive statistics and multivariable logistic regression analyses were performed with data about clinics and the counties they served. In total, 449 CCBHCs were surveyed in the summer of 2022, with a response rate of 56%. The final sample comprised 247 clinics. RESULTS: The number of CCBHC employees per 1,000 people within a CCBHC service area was significantly and positively associated with clinics providing some crisis services directly (mobile crisis response: adjusted OR [AOR]=1.46, 95% CI=1.08-1.98; crisis stabilization services: AOR=1.60, 95% CI=1.17-2.19). Compared with clinics that did not receive a CCBHC Medicaid bundled payment, clinics that received this payment had higher odds of adding mobile crisis response (AOR=2.52, 95% CI=1.28-4.97) and crisis stabilization services (AOR=3.19, 95% CI=1.51-6.72) after becoming a CCBHC. CONCLUSIONS: CCBHC initiatives, particularly CCBHC Medicaid bundled payments, may provide opportunities to increase the availability of behavioral health crisis services, but the sufficiency of this increase for meeting crisis care needs remains unknown.

"Instead, You're Going to a Friend": Evaluation of a Community-Developed, Peer-Delivered Online Crisis Prevention Intervention.

OBJECTIVE: Online communities promote social connection and can be used for formal peer support and crisis intervention. Although some communities have programs to support their members' mental health, few programs have been formally evaluated. The authors present findings from a mixed-methods evaluation of the Stack Up Overwatch Program (StOP), a digital peer support intervention delivered in an online gaming community. METHODS: Data were collected from members of the Stack Up Discord server between June and October 2020 and included chat messages, survey responses, encounter forms (documenting information from private interactions between users and peer supporters), and interviews with peer support team members. The authors analyzed data on demographic characteristics, mental health and crises, use of and experiences with StOP, and chat posts. Thematic analysis and descriptive statistics were combined in a joint display table, with mixed-methods findings explained in narrative form. RESULTS: The findings show that StOP provides users in crisis with a source of mental health support when other options have been exhausted and that military and veteran users valued the connections and friendships they formed while using it. Participants reported that StOP met needs for support and connection when formal services were inaccessible or did not meet their needs, and volunteer peer supporters detailed how StOP's design facilitates use of the intervention. Volunteering offered members of the peer support team a "family feeling" facilitated by the unique chat room structure. CONCLUSIONS: Community-based crisis prevention programs administered through chat rooms may provide valuable support to both users and peer support providers.

Considerations for Psychological Debriefing in the Context of Prolonged Disaster Response.

First responders face greater exposure to potentially traumatic events compared with the general public, which can lead to an increased likelihood of developing mental health concerns. The challenges of disaster relief take a physical and mental toll on first responders. Critical incident stress debriefing (CISD), the widely accepted gold-standard treatment for psychological debriefing, is often applied to offset this toll among first responders. CISD is a manualized seven-stage group intervention that was developed to provide support and aid in coping and to allow individuals who respond to emergencies and disasters to continue working. Substantial evidence has been found for its effectiveness. However, there is a general dearth of evidence about the field of prolonged disaster response, and research is hampered by the difficulties of executing a controlled study in the context of an emergency scenario.

Emergencies in inflammatory rheumatic diseases.

Inflammatory rheumatic diseases (IRDs), encompassing a broad spectrum of chronic disorders, typically necessitate prolonged therapeutic intervention. Nevertheless, these diseases can sometimes manifest as severe emergencies requiring prompt and extensive medical intervention. Urgent intervention is essential for effectively recognizing and managing these situations, as they have the potential to be life-threatening and can result in severe morbidity and mortality. Emergencies in IRDs can occur with different frequencies and manifestations, including nervous system issues, severe infections, thrombosis-emboli, renal crises, gastrointestinal issues, and cardiovascular events. The fact that these events can occur across different IRDs underscores the necessity for heightened awareness and readiness among healthcare professionals. The pathophysiologic mechanisms that cause rheumatic emergencies are complex and involve multiple factors. These emergencies frequently arise due to the interplay between the inflammatory characteristics of rheumatic diseases and different systemic triggers. Early detection and treatment can have a substantial impact on an individual's prognosis in cases of severe and life-threatening disorders that require prompt recognition. Rapid decision-making and urgent care are required to effectively address rheumatic emergencies, as well as the implementation of a diagnostic flowchart. This article provides an overview of the emergencies linked to IRDs, classifying and assessing them individually. This article aims to enhance healthcare professionals' knowledge and awareness of critical situations by examining current recommendations and pathophysiological information. Implementing standardized diagnostic and treatment methods, providing patient education, and conducting continuing research into the underlying mechanisms are essential for enhancing the management of these critical situations and improving patient outcomes.

Effects of Patient-Initiated Brief Admissions on Psychiatric Care Consumption in Borderline Personality Disorder: ARegister-Based Study.

Previous studies have reported that patients with borderline personality disorder (BPD) often have negative experiences in psychiatric inpatient care. To address this issue, a novel intervention known as patient-initiated brief admission (PIBA) has been developed. PIBA offers a constructive approach to crisis management in situations of heightened anxiety, as well as during instances of self-harm and suicidal ideation. The intervention allows patients to directly contact the psychiatric ward to initiate a brief admission lasting 1-3 days. This easily accessible care option during a crisis has the potential to prevent harm to the patient and reduce the need for prolonged hospital stays. The aim of the present study is to investigate the effects of PIBA on psychiatric care consumption among patients diagnosed with BPD. This retrospective register-based study includes data from both inpatient and outpatient care registries for patients diagnosed with BPD. Data were extracted from the National Board of Health and Welfare in Sweden. The study period encompasses 2013-2020, with the PIBA intervention occurring between 2016 and 2019. The sample included 107 patients in the PIBA group and 5659 matched controls. Data were analysed using a difference-in-differences (DiD) approach through ordinary least squares (OLS) regression and ordinal logistic regression. Throughout the 3-year follow-up, both groups exhibited a reduction in the number of days of utilisation of psychiatric inpatient care services. The DiD analysis indicated an additional decrease of 1.5 days at the 6-month mark for the PIBA group (ß = -1.436, SE = 1.531), expanding to 3 days fewer at the 12-month follow-up (ß = -3.590, SE = 3.546), although not statistically significant. For outpatient care, the PIBA group displayed an increase in the number of visits, averaging to half a visit more every 6 months (ß = 0.503, SE = 0.263) compared with the controls. Statistically significant differences were observed for two out of six measurements at the 12-month (ß = 0.960, SE = 0.456) and 18-month follow-up period (ß = 0.436, SE = 0.219). The PIBA group had a statistically significant lower odds of experiencing extended lengths of inpatient care days after the index date than the controls (OR 0.56, 95% CI: 0.44-0.72). In conclusion, PIBA was associated with a significant reduction in the length of individual hospital stays, but not in the overall number of inpatient care days. PIBA may be linked to a shift from longer inpatient care utilisation to outpatient care utilisation. These findings suggest that PIBA may reduce the risk of prolonged hospitalisations for patients who have access to the intervention. Future research should explore the impact of PIBA on healthcare costs and cost-effectiveness, both in relation to health care for the individual and cost-effectiveness in relation to recovery and health.

Peer-Run Respite Approaches to Supporting People Experiencing an Emotional Crisis.

Research shows that guests experience peer-run respites as empowering and safe places where they feel more seen, heard, and respected than they do in conventional settings. This column describes the successful and unique processes of peer-run respites that support guests in emotional crisis and facilitate healing. In a discussion informed by their experiences and the literature, the authors examine how peer-run respites differ from conventional psychiatric crisis response services in their basic philosophy: how emotional crisis is understood, the goal of crisis response, how trauma is viewed, the importance of self-determination, power dynamics, and relationality.

Testing the Impact of a Law Enforcement-Operated Co-responder Program for Youths: A Quasi-Experimental Approach.

OBJECTIVE: The authors examined whether use of a co-responder program reduced the likelihood of an involuntary commitment examination as the disposition of a police encounter with youths experiencing a mental health crisis and 1 year after the initial incident. METHODS: Using a quasi-experimental design, the authors compared 206 incidents that involved the co-response program with 327 incidents that did not involve the program. Propensity score matching was used to balance groups on demographic and incident characteristics. The dependent variables included the disposition of the incident (deescalation or involuntary commitment examination), whether the youths experienced a later involuntary commitment examination within 1 year of the initial intervention, and time to the subsequent examination. Propensity score-weighted binary logistic regression and time-to-event analysis were used. RESULTS: The co-responder program was associated with a significantly lower likelihood of police officer-initiated involuntary commitment examinations and a lower likelihood of an involuntary commitment examination within 1 year. Eighty percent of the incidents that resulted in a co-response involving a police officer and a mental health professional were deescalated, allowing the youth to remain in the community with a safety plan, whereas 17% of incidents with a police-only response ended with crisis deescalation. CONCLUSIONS: These findings provide further support for the implementation of co-responder options that are available to police officers during encounters with children and adolescents experiencing a mental health crisis.

Brief admission by self-referral as an add-on to usual care for individuals with self-harm at risk of suicide: cost-effectiveness and 4-year health-economic consequences after a Swedish randomized controlled trial.

BACKGROUND: Brief Admission by self-referral (BA) is a crisis-management intervention standardized for individuals with self-harm at risk of suicide. We analyzed its health-economic consequences. MATERIALS AND METHODS: BA plus treatment as usual (TAU) was compared with TAU alone in a 12-month randomized controlled trial with 117 participants regarding costs for hospital admissions, coercive measures, emergency care and health outcomes (quality-adjusted life years; QALYs). Participants were followed from 12 months before baseline to up to five years after. RESULTS: Over one year BA was associated with a mean annual cost reduction of 4800 or incremental cost of 4600 euros, depending on bed occupancy assumption. Cost-savings were greatest for individuals with >180 admission days in the year before baseline. In terms of health outcomes BA was associated with a QALY gain of 0.078. Uncertainty analyses indicated a significant QALY gain and ambiguity in costs, resulting in BA either dominating TAU or costing 59 000 euros per gained QALY. CONCLUSION: BA is likely to produce QALY gains for individuals living with self-harm and suicidality. Cost-effectiveness depends on targeting high-need individuals and comparable bed utilization between BA and other psychiatric admissions. Future research should elaborate the explanatory factors for individual variations in the usage and benefit of BA.

"Put your personality into the call": A qualitative interview study illuminating strategies for improving men's engagement on crisis helplines.

BACKGROUND: Crisis telephone helplines are an integral part of community suicide prevention. Despite high male suicide rates, men's experiences of these services are poorly understood. The current study explored men's perspectives of their interactions with helpline counsellors to understand how their engagement on helplines can be enhanced. METHOD: Sixteen men (19-71 years) who had previously used a mental health or crisis helpline in Australia completed individual semi-structured interviews about their experiences. Data were analysed using interpretive descriptive methodologies. RESULTS: Two themes derived from the data related to how men engaged with counsellors on helpline services. First, men emphasized the importance of helpline counsellors creating and maintaining an authentic connection across the call, providing suggestions for strategies to secure connection. Second, men discussed how counsellors can facilitate outcomes through offering space for their narratives and aiding in referrals to other support services when required. CONCLUSIONS: Findings highlight the value of crisis helplines for men's suicide prevention services while identifying target areas to improve engagement. We discuss implications for the findings including suggestions for gender-sensitive care within crisis helplines.

Integrated psychological intervention programme for frontline healthcare workers during the COVID-19 pandemic. A qualitative study / Programa integrado de intervenciones psicológicas de emergencia en sanitarios durante la pandemia de la COVID-19. Estudio cualitativo

Introduction: The outbreak of the COVID-19 pandemic put at risk the resilience of health-care professionals by exposing them to high levels of stress. Our aim was to identify key elements for implementing the STEP programme, a psychological support service for healthcare professionals.Methods: qualitative design. The study participants were hospital healthcare staff. Anon-ymous questionnaires and transcriptions of group interventions and focus groups were used to identify professionals’ preferences to receiving psychological support, needs, concerns, resilience (STEP1.0); constrained emotions and associated thoughts (STEP1.5); perception of self-efficacy on managing emotions (STEP2.0); and the professionals’ profile requiring individual therapy.Results: Three hundred professionals participated in the study, 100.0% in STEP 1.0 , 27.3% in STEP 1.5, 2.7% in STEP 2.0, and 10.0% in individual interventions. Two hundred and three (67.7%) participants reflected in the survey that they would prefer access to a face-to-face psychological service during working hours. Three consecutive phases with specific needs and concerns were identified: The “cognitive” phase, at the beginning of the pandemic, when infection and self-efficacy were major concerns, the “ventilation” phase, when constrained emotions associated with several factors were expressed; and the “recovery” phase, when the clinical overload decreased and professionals were able to focus on emotion manage-ment training. Several personal characteristics associated with referral to individual therapy were identified. Conclusions: The key characteristics of a psychological support service are proximity, face-to-face interaction during working shifts, and a chronological phase system adapted to dif-ferent emerging needs.(AU)

Introducción: El estallido de la pandemia de la COVID-19 puso en riesgo la resiliencia de los profesionales sanitarios exponiéndolos a alto riesgo de estrés. Nuestro objetivo consistió en identificar elementos clave para implementar un servicio de apoyo psicológico para pro-fesionales.Método: Diseño cualitativo. Participaron profesionales a nivel hospitalario. Se utilizaron cuestionarios anónimos, transcripciones de intervenciones grupales y grupo focal. Se consideraron las variables asociadas a las herramientas de intervención psicológica im-plementadas: STEP 1.0, necesidades, preocupaciones y resiliencia; STEP 1.5, emociones contenidas y pensamientos asociados; STEP 2.0, percepción de autoeficacia en gestión de emociones. Características de profesionales asociadas a terapia individual; así como el método elegido para recibir apoyo psicológico. Resultados: Participaron 300 profesionales, 100.0% en STEP 1.0, 27.3% en STEP 1.5, 2.7% en STEP 2.0 y 10.0% en intervenciones individuales. En 203 cuestionarios los profesionales preferían un servicio psicológico presencial y durante las horas de trabajo. Se identificaron 3 fases consecutivas con necesidades y preocupaciones específicas: Fase “Cognitiva”, incial, cuando la infección y autoeficacia preocupaban más. Fase de “Ventilación” cuando se expresaron emociones contenidas asociadas a varios factores. Fase de “Recuperación”, cuando los profesionales afrontaron la gestión de emociones. Se identificaron característi-cas asociadas a la derivación a terapia individual. Conclusión: Las características clave de un servicio de apoyo psicológico son la proximi-dad, presencialidad, activarse en turnos laborales y seguir un sistema cronológico de fases adaptado a las distintas necesidades emergentes.(AU)

Evidence-based brief interventions targeting acute mental health presentations for children and adolescents: systematic review.

BACKGROUND: Brief intervention services provide rapid, mobile and flexible short-term delivery of interventions to resolve mental health crises. These interventions may provide an alternative pathway to the emergency department or in-patient psychiatric services for children and young people (CYP), presenting with an acute mental health condition. AIMS: To synthesise evidence on the effectiveness of brief interventions in improving mental health outcomes for CYP (0-17 years) presenting with an acute mental health condition. METHOD: A systematic literature search was conducted, and the studies' methodological quality was assessed. Five databases were searched for peer-reviewed articles between January 2000 and September 2022. RESULTS: We synthesised 30 articles on the effectiveness of brief interventions in the form of (a) crisis intervention, (b) integrated services, (c) group therapies, (d) individualised therapy, (e) parent-child dyadic therapy, (f) general services, (g) pharmacotherapy, (h) assessment services, (i) safety and risk planning and (j) in-hospital treatment, to improve outcomes for CYP with an acute mental health condition. Among included studies, one study was rated as providing a high level of evidence based on the National Health and Medical Research Council levels of evidence hierarchy scale, which was a crisis intervention showing a reduction in length of stay and return emergency department visits. Other studies, of moderate-quality evidence, described multimodal brief interventions that suggested beneficial effects. CONCLUSIONS: This review provides evidence to substantiate the benefits of brief interventions, in different settings, to reduce the burden of in-patient hospital and readmission rates to the emergency department.