Patient Flow and Reutilization of Crisis Services Within 30 Days in a Comprehensive Crisis System.

OBJECTIVE: Crisis services are undergoing an unprecedented expansion in the United States, but research is lacking on crisis system design. This study describes how individuals flow through a well-established crisis system and examines factors associated with reutilization of such services. METHODS: This cross-sectional study used Medicaid claims to construct episodes describing the flow of individuals through mobile crisis, specialized crisis facility, emergency department, and inpatient services. Claims data were merged with electronic health record (EHR) data for the subset of individuals receiving care at a crisis response center. A generalized estimating equation was used to calculate adjusted odds ratios for demographic, clinical, and operational factors associated with reutilization of services within 30 days of an episode's end point. RESULTS: Of 41,026 episodes, most (57.4%) began with mobile crisis services or a specialized crisis facility rather than the emergency department. Of the subset (N=9,202 episodes) with merged EHR data, most episodes (63.3%) were not followed by reutilization. Factors associated with increased odds of 30-day reutilization included Black race, homelessness, stimulant use, psychosis, and episodes beginning with mobile crisis services or ending with inpatient care. Decreased odds were associated with depression, trauma, and involuntary legal status. Most (59.3%) episodes beginning with an involuntary legal status ended with a voluntary status. CONCLUSIONS: Crisis systems can serve a large proportion of individuals experiencing psychiatric emergencies and divert them from more restrictive and costly levels of care. Understanding demographic, clinical, and operational factors associated with 30-day reutilization may aid in the design and implementation of crisis systems.

Community-Based Crisis Services, Specialized Crisis Facilities, and Partnerships With Law Enforcement.

How a community responds to behavioral health emergencies is both a public health issue and a social justice issue. Individuals experiencing a behavioral health crisis often receive inadequate care in emergency departments, boarding for hours or days while awaiting treatment. Such crises also account for a quarter of police shootings and 2 million jail bookings per year, and racism and implicit bias magnify these problems for people of color. Fortunately, the new 988 mental health emergency number compounded with police reform movements have created momentum for building behavioral health crisis response systems that deliver comparable quality and consistency of care as we expect for medical emergencies. This paper provides an overview of the rapidly evolving landscape of crisis services. The authors discuss the role of law enforcement and various approaches to lessening the impact on individuals experiencing behavioral health emergencies, especially for historically marginalized populations. The authors provide an overview of the crisis continuum, including crisis hotlines, mobile teams, observation units, crisis residential programs, and peer wraparound services that can help ensure that linkage to aftercare is successful. The authors also highlight opportunities for psychiatric leadership, advocacy, and strategies for creating a well-coordinated crisis system that meets the needs of the community.

Cops, Clinicians, or Both? Collaborative Approaches to Responding to Behavioral Health Emergencies.

How a community responds to behavioral health emergencies is both a public health issue and social justice issue. Individuals experiencing a behavioral health crisis often receive inadequate care in emergency departments (EDs), boarding for hours or days while waiting for treatment. Such crises also account for a quarter of police shootings and >2 million jail bookings per year. Racism and implicit bias magnify these problems for people of color. Growing support for reform provides an unprecedented opportunity for meaningful change, but solutions to this complex issue will require comprehensive systemic approaches. As communities grapple with behavioral health emergencies, the question is not just whether law enforcement should respond to behavioral health emergencies but how to reduce unnecessary law enforcement contact and, if law enforcement is responding, when, how, and with what support. This policy article reviews best practices for law enforcement crisis responses, outlines the components of a comprehensive continuum-of-crisis care model that provides alternatives to law enforcement involvement and ED use, and offers strategies for collaboration and alignment between law enforcement and clinicians toward common goals. Finally, policy considerations regarding stakeholder engagement, financing, data management, legal statutes, and health equity are presented to assist communities interested in taking steps to build these needed solutions.

Effect of a Virtual Patient Navigation Program on Behavioral Health Admissions in the Emergency Department: A Randomized Clinical Trial.

IMPORTANCE: The number of patients presenting to emergency departments (EDs) for psychiatric care continues to increase. Psychiatrists often make a conservative recommendation to admit patients because robust outpatient services for close follow-up are lacking. OBJECTIVE: To assess whether the availability of a 45-day behavioral health-virtual patient navigation program decreases hospitalization among patients presenting to the ED with a behavioral health crisis or need. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial enrolled 637 patients who presented to 6 EDs spanning urban and suburban locations within a large integrated health care system in North Carolina from June 12, 2017, through February 14, 2018; patients were followed up for up to 45 days. Eligible patients were aged 18 years or older, with a behavioral health crisis and a completed telepsychiatric ED consultation. The availability of the behavioral health-virtual patient navigation intervention was randomly allocated to specific days (Monday through Friday from 7 am to 7 pm) so that, in a 2-week block, there were 5 intervention days and 5 usual care days; 323 patients presented on days when the program was offered, and 314 presented on usual care days. Data analysis was performed from March 7 through June 13, 2018, using an intention-to-treat approach. INTERVENTIONS: The behavioral health-virtual patient navigation program included video contact with a patient while in the ED and telephonic outreach 24 to 72 hours after discharge and then at least weekly for up to 45 days. MAIN OUTCOMES AND MEASURES: The primary outcome was the conversion of an ED encounter to hospital admission. Secondary outcomes included 45-day follow-up encounters with a self-harm diagnosis and postdischarge acute care use. RESULTS: Among 637 participants, 358 (56.2%) were men, and the mean (SD) age was 39.7 (16.6) years. The conversion rates were 55.1% (178 of 323) in the intervention group vs 63.1% (198 of 314) in the usual care group (odds ratio, 0.74; 95% CI, 0.54-1.02; P = .06). The percentage of patient encounters with follow-up encounters having a self-harm diagnosis was significantly lower in the intervention group compared with the usual care group (36.8% [119 of 323] vs 45.5% [143 of 314]; P = .03). CONCLUSIONS AND RELEVANCE: Although the primary result did not reach statistical significance, there is a strong signal of potential positive benefit in an area that lacks evidence, suggesting that there should be additional investment and inquiry into virtual behavioral health programs. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03204643.

Provider-Payer Partnerships as an Engine for Continuous Quality Improvement.

The authors describe a quality improvement approach in which a crisis center and a payer collaborate to improve care. Each crisis visit is considered as a potentially missed opportunity for community stabilization. Daily data on crisis visits are sent to the payer for a more up-to-date analysis of trends than is possible with financial claims data, which may lag behind services provided by up to 90 days. Using these trend data, the two organizations collaborate to identify patterns that lead to opportunities for improvement and develop multiple rapid-cycle projects for better management of services, resulting in significant decreases in readmissions and in the number of high utilizers.

Using Lean to Rapidly and Sustainably Transform a Behavioral Health Crisis Program: Impact on Throughput and Safety.

BACKGROUND: Lean has been increasingly applied in health care to reduce waste and improve quality, particularly in fast-paced and high-acuity clinical settings such as emergency departments. In addition, Lean's focus on engagement of frontline staff in problem solving can be a catalyst for organizational change. In this study, ConnectionsAZ demonstrates how they applied Lean principles to rapidly and sustainably transform clinical operations in a behavioral health crisis facility. METHODS: A multidisciplinary team of management and frontline staff defined values-based outcome measures, mapped the current and ideal processes, and developed new processes to achieve the ideal. Phase I was implemented within three months of assuming management of the facility and involved a redesign of flow, space utilization, and clinical protocols. Phase II was implemented three months later and improved the provider staffing model. Organizational changes such as the development of shift leads and daily huddles were implemented to sustain change and create an environment supportive of future improvements. RESULTS: Post-Phase I, there were significant decreases (pre vs. post and one-year post) in median door-to-door dwell time (343 min vs. 118 and 99), calls to security for behavioral emergencies (13.5 per month vs. 4.3 and 4.8), and staff injuries (3.3 per month vs. 1.2 and 1.2). Post-Phase II, there were decreases in median door-to-doctor time (8.2 hours vs. 1.6 and 1.4) and hours on diversion (90% vs. 17% and 34%). CONCLUSIONS: Lean methods can positively affect safety and throughput and are complementary to patient-centered clinical goals in a behavioral health setting.

A Pilot Study Using Mixed GPS/Narrative Interview Methods to Understand Geospatial Behavior in Homeless Populations.

Tracking the movements of homeless populations presents methodological difficulties, but understanding their movements in space and time is needed to inform optimal placement of services. This pilot study developed, tested, and refined methods to apply global positioning systems (GPS) technology paired with individual narratives to chronicle the movements of homeless populations. Detail of methods development and difficulties encountered and addressed, and geospatial findings are provided. A pilot sample of 29 adults was recruited from a low-demand homeless shelter in the downtown area of Fort Worth, Texas. Pre- and post-deployment interviews provided participant characteristics and planned and retrospectively-reported travels. Only one of the first eight deployments returned with sufficient usable data. Ultimately 19 participants returned the GPS device with >20 h of usable data. Protocol adjustments addressing methodological difficulties achieved 81 % of subsequent participants returning with sufficient usable data. This study established methods and demonstrated feasibility for tracking homeless population travels.

Crisis Reliability Indicators Supporting Emergency Services (CRISES): A Framework for Developing Performance Measures for Behavioral Health Crisis and Psychiatric Emergency Programs.

Crisis and emergency psychiatric services are an integral part of the healthcare system, yet there are no standardized measures for programs providing these services. We developed the Crisis Reliability Indicators Supporting Emergency Services (CRISES) framework to create measures that inform internal performance improvement initiatives and allow comparison across programs. The framework consists of two components-the CRISES domains (timely, safe, accessible, least-restrictive, effective, consumer/family centered, and partnership) and the measures supporting each domain. The CRISES framework provides a foundation for development of standardized measures for the crisis field. This will become increasingly important as pay-for-performance initiatives expand with healthcare reform.

A prospective study of the associations among housing status and costs of services in a homeless population.

OBJECTIVE: The complex needs of homeless populations result in use of a wide range of services and high costs for housing programs and psychiatric and general medical care. Allocation of resources often is not congruent with assessed needs. A series of cost-congruence hypotheses was developed to test assumptions that needs are associated with resources provided for appropriate services in homeless populations. METHODS: Individuals (N=255) who were homeless were followed for two years and were categorized by housing status over time (consistently housed, housed late, lost housing, or consistently homeless). Detailed information about the individuals was obtained at baseline, and follow-up data were collected one and two years later. Extensive data about the costs of services provided by type (medical, psychiatric, substance abuse, and homeless maintenance and amelioration) were derived from 23 agencies, and service use information was collected from the agencies and by self-report. Multiple regression models were used to test the hypotheses. RESULTS: Medical, psychiatric, and homeless maintenance costs varied by housing status. Serious mental illness predicted costs for psychiatric services, as expected, but also costs for substance abuse services and acute behavioral health care and total costs. Alcohol use disorders predicted substance abuse service costs. CONCLUSIONS: This study followed a homeless cohort prospectively and provided estimates of costs of service use derived from a large number of agencies. This research increases the understanding of patterns of service use in a homeless population and informs the provision of services appropriate to the complex needs of this difficult-to-serve population.

Deriving costs of service use among an urban homeless population.

The purpose of this study was to describe a novel approach to calculating service use costs across multiple domains of service for homeless populations. A randomly-selected sample of homeless persons was interviewed in St. Louis, MO and followed for 2 years. Service- and cost-related data were collected from homeless individuals and from the agencies serving them. Detailed interviews of study participants and of agency personnel in specific domains of service (medical, psychiatric, substance abuse, homeless maintenance, and homeless amelioration services) were conducted using a standardized approach. Service utilization data were obtained from agency records. Standardized service-related costs were derived and aggregated across multiple domains from agency-reported data. Housing status was not found to be significantly associated with costs. Although labor intensive, this approach to cost estimation allows costs to be accurately compared across domains. These methods could potentially be applied to other populations.

Neuroplasticity in the mesolimbic system induced by natural reward and subsequent reward abstinence.

BACKGROUND: Natural reward and drugs of abuse converge on the mesolimbic system, where drugs of abuse induce neuronal alterations. Here, we tested plasticity in this system after natural reward and the subsequent impact on drug responses. METHODS: Effects of sexual experience in male rats on behavioral sensitization and conditioned place preference associated with d-amphetamine (AMPH) and Golgi-impregnated dendrites and spines of nucleus accumbens (NAc) cells were determined. Moreover, the impact of abstinence from sexual behavior in experienced males on these parameters was tested. RESULTS: First, repeated sexual behavior induced a sensitized locomotor response to AMPH compared with sexually naive control subjects observed 1, 7, and 28 days after last mating session. Second, sexually experienced animals formed a conditioned place preference for lower doses of AMPH than sexually naive males, indicative of enhanced reward value of AMPH. Finally, Golgi-Cox analysis demonstrated increased numbers of dendrites and spines in the NAc core and shell with sexual experience. The latter two alterations were dependent on a period of abstinence of 7-10 days. CONCLUSIONS: Sexual experience induces functional and morphological alterations in the mesolimbic system similar to repeated exposure to psychostimulants. Moreover, abstinence from sexual behavior after repeated mating was essential for increased reward for drugs and dendritic arbors of NAc neurons, suggesting that the loss of sexual reward might also contribute to neuroplasticity of the mesolimbic system. These results suggest that some alterations in the mesolimbic system are common for natural and drug reward and might play a role in general reinforcement.

Mixing pleasures: review of the effects of drugs on sex behavior in humans and animal models.

Drugs of abuse act on the brain circuits mediating motivation and reward associated with natural behaviors. There is ample evidence that drugs of abuse impact male and female sexual behavior. First, the current review discusses the effect of drugs of abuse on sexual motivation and performance in male and female humans. In particular, we discuss the effects of commonly abused drugs including psychostimulants, opiates, marijuana/THC, and alcohol. In general, drug use affects sexual motivation, arousal, and performance and is commonly associated with increased sexual risk behaviors. Second, studies on effects of systemic administration of drugs of abuse on sexual behavior in animals are reviewed. These studies analyze the effects on sexual performance and motivation but do not investigate the effects of drugs on risk-taking behavior, creating a disconnect between human and animal studies. For this reason, we discuss two studies that focus on the effects of alcohol and methamphetamine on inhibition of maladaptive sex-seeking behaviors in rodents. Third, this review discusses potential brain areas where drugs of abuse may be exerting their effect on sexual behavior with a focus on the mesolimbic system as the site of action. Finally, we discuss recent studies that have brought to light that sexual experience in turn can affect drug responsiveness, including a sensitized locomotor response to amphetamine in female and male rodents as well as enhanced drug reward in male rats.

Mating activates NMDA receptors in the medial preoptic area of male rats.

Studies have emphasized the role of the medial preoptic area (MPOA) as an important site for the regulation of male sexual behavior. Indeed, ablations of the MPOA impair sexual behavior, whereas stimulation of the MPOA enhances behavior. Furthermore, neural activity in the MPOA increases with mating. The current study tested the hypothesis that activation of N-methyl-D-aspartate (NMDA) receptors occurs in MPOA neurons and is essential for the expression of male sexual behavior in rats. Results indicate that nearly all MPOA neurons that expressed Fos following mating also contained the NR1 subunit of NMDA receptors. Furthermore, mating increased phosphorylation, thus activation, of NR1 in the MPOA. Additionally, blocking NMDA receptors significantly decreased mating-induced Fos expression and mating-induced phosphorylation of NMDA receptors and impaired male sexual behavior. These results provide evidence that mating activates NMDA receptors in the MPOA and that this activation is important for the expression of male sexual behavior.

Sexual behavior and sex-associated environmental cues activate the mesolimbic system in male rats.

The mesolimbic system plays an important role in the regulation of both pathological behaviors such as drug addiction and normal motivated behaviors such as sexual behavior. The present study investigated the mechanism by which this system is endogenously activated during sexual behavior. Specifically, the effects of sexual experience and sex-related environmental cues on the activation of several components of the mesolimbic system were studied. The mesolimbic system consists of a dopaminergic projection from the ventral tegmental area (VTA) to the nucleus accumbens (NAc). Previous studies suggest that these neurons are under tonic inhibition by local GABA interneurons, which are in turn modulated by mu opioid receptor (MOR) ligands. To test the hypothesis that opioids are acting in the VTA during sexual behavior, visualization of MOR internalization in VTA was used as a marker for ligand-induced activation of the receptor. Significant increases in MOR internalization were observed following copulation or exposure to sex-related environmental cues. The next goal was to determine if sexual behavior activates dopamine neurons in the VTA, using tyrosine hydroxylase as a marker for dopaminergic neurons and Fos-immunoreactivity as a marker for neuronal activation. Significant increases in the percentage of activated dopaminergic neurons were observed following copulation or exposure to sex-related environmental cues. In addition, mating and sex-related cues activated a large population of nondopaminergic neurons in VTA as well as neurons in both the NAc Core and Shell. Taken together, our results provide functional neuroanatomical evidence that the mesolimbic system is activated by both sexual behavior and exposure to sex-related environmental cues.