BeHealth.Today | Mobile Psych Treatment Team

1. The Mobile Psychiatric
Treatment Team
Lisa Krekler, MSW, LCSW

2. The Mobile Psychiatric
Treatment Team
An Alternative to Emergency Room Boarding
and Inpatient Psychiatric Hospitalization

3. Introduction
The Problem We See
• People are seeking mental health treatment in the Emergency Room (ER) because
there is a lack of resources both inpatient and outpatient.
• Patients are being evaluated and languish in the ER often for days while awaiting
inpatient psychiatric hospitalization because they were too acute for outpatient
treatment.
• Patients would wait in the ER without treatment.
• After several days, the patient’s crisis would typically resolve and they would
discharge, without ever receiving any psychiatric treatment.

4. Introduction The Impact of the Problem
• Lack of outpatient mental health resources.
• The closure of inpatient hospitals leaves a severe shortage of
beds across the nation.
• Funding has decreased over the years for mental health
programs.
• Federal and State laws have not been updated to prevent ER
boarding.

5. Problem Statement
How Might We help people who are suicidal and
being held in the ER untreated for more than 24
hours while awaiting transfer to an inpatient
psychiatric bed.

6. Project Plan
The Idea Guy | Project Plan : MobilePsych
Problem Statement: How might we help people in a behavioral health crisis in the emergency room obtain mental health care, stabilize and discharge to appropriate levels of care within 24-hours.
Process Tools Details 3-12-19 3-13-19 3-14-19 3-15-19 3-16-19 3-17-19 3-23-19
Empathize
Research What we will research
Observation What we will observe how people are impacted
Engagement: Focus Groups How we will engage stakeholders
Ethnography How we will experience
Define
Synthesize Identify needs and insights
Reframe Expand problem to include all perspectives
Update Problem Statement Revise problem statement(s) based on what we learned
Ideate
Divergent Sketching Diverse concepts that may solve the problem
Collect Feedback Feedback on concepts
Convergent Sketching Selction of concept(s) with greatest potential
Prototype
Develop Prototype 1.0 Representation of the concept for segments
Develop Prototype 1.1 Updated prototype based on test
Test
Collect Feedback 1.0 Feedback from segments
Collect Feedback 1.1 Feedback from segments
Share
Story Sharing Template Formal presentation of what we have learned
Distribute Story Implement solutions
Collect Feedback Monitor, measure and report
Process Tools Details 3-12-19 3-13-19 3-14-19 3-15-19 3-16-19 3-17-19 3-23-19

7. Empathize
Research
• Lack of outpatient mental health treatment options.
• Decreased number of inpatient psychiatric beds.
• Lack of alternatives to manage behavioral health crises
24-hours a day.
• ER Boarding has become a national problem.
What was Learned
• Psychiatric ER boarding length of stays can last hours to
several days.
• ER boarding is costly to Hospitals, Insurers, and
Consumers and prevents access to timely treatment.
• Patients receive NO mental health treatment.

8. Empathize Observation & What was Learned
• Patients in mental health crisis are held in hallway beds.
• Stripped of their belongings and placed in hospital gown.
• Monitored for safety by security guards or sitters.
• ER Physicians defer to inpatient treatment.
• Nurses struggle to meet the needs and demands of the
patients.
• Patients and their support systems report not enough being
done to treat the presenting problem.
• Crisis is impacted by the problem not being addressed.

9. Empathize Engagement & What was Learned
• Lack of mental health training, long boarding times and general
discomfort has been cited by ER physicians, and nurses, thusly,
inadequate care during a crisis only impacts the initial crisis.
• From the patient’s perspective, ERs are overstimulating, lack
privacy, increase stress, increase stigma, rights removed, which
ultimately compound the reason for the admission to the ER.
• ER exacerbates the presenting problem, increases stigma and
highlights the disparity in mental health treatment.

10. Define
• The ER has been the main point of entry for psychiatric emergencies
and leads to ER boarding.
• Inpatient psychiatric facilities and beds have decreased leading to
inadequate access to inpatient levels of care.
• The ER is not a therapeutic healing environment for individuals in
acute mental health crisis.
• There is a marked disparity in the treatment of individuals
presenting with mental health issues versus medical issues.

11. Define Reframe
• Patients in a psychiatric crisis need to have access to specialized
immediate treatment by providers who are trained to treat the
presenting problem. By bringing a mobile team of behavioral health
providers to the patient, we can challenge the norm that patients
can only be treated in an inpatient psychiatric setting.
• The MPTT will consists of behavioral health providers who can
intervene in the immediate psychiatric crisis. Utilizing the providers
from an inpatient hospital setting and making them mobile.

12. DefineUpdated Problem Statement
How Might We help people in a behavioral health
crisis in the emergency room obtain mental health
care, stabilize and discharge to appropriate levels of
care within 24-hours.

13. Prototype
Mobile
Psychiatric
Treatment
Team
• Psychiatrist available virtually
24-hours a day.
• Psychiatric Registered Nurse
• Licensed Clinical Social Worker
• Mental Health Worker
• Peer Support Specialist

14. Prototype
Mobile
Psychiatric
Treatment
Team
Multidisciplinary
Behavioral Health
Team 24/7
Individual and group
therapy
Thorough
psychiatric
evaluation
Medication
management by a
Psychiatrist
Safety & Coping
Plan
Follow-up and
navigational support
post discharge for
30 days

15. Ideate
Patient is evaluated
by Triage RN in ER
Patient arrives to
ER in behavioral
health crisis
Patient is evaluated
by ER Physician
ER Physician refers
to MPTT
Patient is
transferred from ER
to Crisis Unit
Patient is admitted
to the Psychiatric
Crisis Unit
Patient is evaluated
by Psychiatric RN
Patient oriented to
unit and completes
IPAD assessments
RN & MHW
complete patient
safety check
Patient evaluated
by psychiatrist
(virtual) <4 hours
Medication
consultation by
Psychiatrist
Family meeting
with patient & SW
if indicated
SW and Patient
work to engage
friends & family
Patient invited to
WRAP group
therapy
MHW works with
patient on WRAP
MPTT Flow Chart Process in the ER
MPTT Admission Process
Patient
administered meds
as needed by RN
Patient meets with
SW for Safety Plan
development
Safety Checks &
Continued
monitoring by staff
Therapy group
Coping skills
Social Worker and
Patient develop
plan for discharge
MPTT Treatment & Crisis Intervention
Patient meets with
RN to re-assess
patient
Patient is safe to dc
home / lower level
of care
Patient is still
needing acute
psychiatric care
Patient is referred
to Psychiatrist for
final disposition
Patient is dc home
or lower level of
care
Patient referred to
inpatient
psychiatric hosp.
Patient transferred
to inpatient level of
care
Final Disposition
Patient is referred
to Psychiatrist for
final disposition
SW follow-up with
patient <7 days

16. Ideate
Feedback & What was Learned
• To address ER boarding, first we need to develop a unit in the
hospital to get people out of the ER setting.
• Need to develop a unit for the MPTT to treat the patient within the
hospital setting.

17. Prototype: MPTT Unit

18. Prototype: MPTT Unit
• Group milieu setting
• Lounge chairs (not beds).
• Patients may wear their own clothes.
• Staff working with patients on the unit
for 23 hours 59 minutes.
• Monitoring for safety.

19. Ideate
Convergent Sketch
ER staff call the MPTT intake line and the team is deployed to the ER.
Patient is evaluated by the ER physician and medically stabilized. The ER
physician refers patient to the MPTT due to mental health condition identified.
Patient arrives to the emergency room (ER) in a behavioral health crisis and is
triaged by the ER RN.
MPTT Psychiatric Registered Nurse (PRN), Mental Health Worker (MHW) and
Social Worker (SW) arrive to ER within 30 minutes.
MPTT intake staff calls the Psychiatrist (MD) to discuss clinical and admission
orders for patient.
Verbal handoff and documentation are provided from the ER RN to the PRN.
The patient is transferred to the MPTT unit out of the ER.
Patient is evaluated by PRN for initial nursing assessment, PRN begins
discharge planning discussion with patient. Patient is provided IPAD to complete
clinical self-reporting measures. PRN and MHW complete patient safety check.
Safety checks continue every 15 minutes.
Patient evaluated virtually by MD within four hours for history and physical
evaluation and medication consultation. MD discusses discharge plans.
Biopsychosocial evaluation conducted by SW and connections made to engage
family, peers. Discharge planning discussion continues and Conjoint meeting
with patient’s support system initiated in person or virtually.
The MHW works with patient on the Wellness Recovery Action Plan (WRAP) with
patient (Copeland, 2002) either individually or in group.
The SW works with patient individually on the WRAP developing safety & coping
plan. SW solidifies discharge plans with patient. Individual therapy provided.
PRN administers medication as needed. Patient encouraged to participate in
group therapy available working on coping skills, safety planning and WRAP.
The Mobile Psychiatric
Treatment Team Work
Flow

20. Ideate
Convergent Sketch
The Mobile Psychiatric
Treatment Team Work
Flow Continued.
PRN conducts 12-hour nursing assessment with patient and preparation for
discharge continues. SW, PRN & MHW and MD consult. Final disposition
determined.
Patient determined to be safe
to discharge to lower level of
care.
Patient is requiring longer
stabilization and is meeting
criteria for psychiatric admission.
Patient referred to MD for
final evaluation and
discharge is finalized.
SW meets with patient to
schedule follow-up
appointments, provide
resources, confirm discharge
plans and preferences for
transportation home or other
lower level of care.
Connection with support
system encouraged.
Patient is discharged within
23 hours 59 minutes.
SW provides ongoing support by
telephone or virtually contacting patient
at day three and seven to ensure
successful discharge planning and
connections to community providers.
SW remains available up to 30 days as
needed.
PRN calls for bed availability in
community and begins referral
process.
MPTT continue to work with
patient providing ongoing support
and safety monitoring.
PRN secures bed for patient at a
hospital and arranges ambulance
transportation for transfer.
MD orders transfer for inpatient
level of care.
Patient is discharged and
transferred to inpatient facility
within 23 hours and 59 minutes.

21. Test How will the Prototype be tested?
• Propose a 1 year MPTT pilot in an ER in San Diego, CA.
• Develop partnerships with local Hospital ERs & County
agencies.

22. Test What are the Specific Aims?
1. Developing a MPTT Unit within the hospital setting to provide
psychiatric crisis intervention designed to de-escalate the crisis by
providers who are trained in crisis intervention and safety management.
2. After patients are stabilized medically in the ER, they will be
transferred to the MPTT Unit and will be offered treatment and then
dispositioned within 24 hours.
3. Decreasing the disparity of patients seeking mental health care by
ensuring acute mental health treatment in a non-stigmatizing setting.
4. Treating 1,825 people in the first year of the program in one hospital
setting.

23. Outcomes How this will innovate behavioral health?
• Treating the patients immediate
mental health needs.
• 24 hour Crisis Intervention
• Patients linked to community for
continued services.
• Patients will have access to
team for up to 30 days post
discharge.
• Decreased reliance upon
inpatient hospitals.
• Decreased ER boarding.
• Decreased 30 day
readmissions.
• Increased Equity in Mental
Health treatment.
• Decreased Stigma.
• Cost Savings to Consumers,
Hospitals and Insurance
Companies

24. Summary What will this require to move forward?
• The MPTT will need to develop partnerships between with local
hospitals and County agencies.
• Obtain funding.
• Develop a MPTT Unit within the hospital setting.
• Develop the policies and procedures and hire the team.
• Implementation & Testing

25. Summary
● The mental health system needs to address the problem of people
with mental health conditions being detained in the ER without care,
but we have been stuck in the norms of a system that no longer fits
needs of the community.
● This innovative 23-hour crisis interventions will provide a cost
savings to hospitals, insurance companies and consumers.
● It is time to change the trajectory of care and implement
the Mobile Psychiatric Treatment Team in San Diego, CA.

26. The Mobile Psychiatric
Treatment Team
Mission
The Mission of the MPTT is to bring mental health
treatment directly to the patient where the patient is in
the community ensuring dignity and respect in a non-
stigmatizing setting while ensuring safety at the least
restrictive level of care.
Vision
The Vision of the MPTT is to promote mental wellness
and build connections ensuring a healthier generation.

27. Q&A
Questions, comments and suggestions.