Behavioral health leaders often talk about building a continuum of care, but what that looks like on the ground may vary. At Becker’s Behavioral Health Summit in November, leaders from across the industry gathered to discuss how systems are working to strengthen that continuum from prevention to stabilization and where it breaks down.
Editor’s note: These responses have been lightly edited for clarity.
Question: When talking about crisis response, the term continuum of care often comes up for each of you. What does that continuum look like in practice at your organization? And where do you see the biggest gaps that still need to be filled?
Steven Airhart. Group Director and CEO for Hartgrove Behavioral Health System and Garfield Park Behavioral Hospital for UHS of Delaware (Prussia, Pa.): When you think of what the hospital’s purpose is, our purpose is to provide short-term acute care crisis stabilization. That means that we’re working with the patients that are most psychiatrically acutely ill, thinking of it like an intensive care unit. Our job on the inpatient side is to stabilize the crisis and on day one begin working on transitional care — the transitional programming that is most appropriate for them, which might include portion intensive outpatient or outpatient services.
We’ve also in Illinois started what we call the school-based services. Part of our commitment to psychiatry of the future is bringing the services to where the patient is. So we have about 150 schools in Illinois where we provide a therapist in that school to be able to meet the needs of those patients in that specific area. This includes medication management, individual therapy, family therapy, as well as group therapy. In addition to that, we work heavily with the police department as well as with the schools.
Obviously it goes without saying we have done extensive work with the emergency departments. I think oftentimes psychiatric deserts are overlooked. We continue to find substantial vacancies throughout the country where there are no psychiatrists, there are no psychologists, nurse practitioners, etc. We’re trying to do everything we can to fulfill that need and bring our services to them. So partly what we have done at Hart Grove and Garfield Park is to build that outpatient continuum so that we’re filling that void. This year alone, we’ve had about 51,000 outpatient contacts alone, because within Illinois there’s not a plethora of outpatient services. That’s what we’re doing to try to fulfill as much of that need as possible.
Elicia Bunch. Vice President of Behavioral Health for UCHealth (Aurora, Colo.): When I think about continuum of care, I think about, where are patients showing up in crisis, and how do we identify the crisis? Within UCHealth, we do about a million suicide risk screens a year. As we look at the risk stratification of those patients who are showing up in our medical settings having services that we know we can refer to — because it’s very frustrating for providers when we ask them to do a screen, and then we don’t have a resource for them to connect patients to. It’s very difficult to make a referral because it’s very hard to access services. People who die by suicide, half of them saw their primary care provider within a month of their death, and 85% saw a healthcare provider within about a year. We know there’s lots of stats on people who have diagnosed behavioral health conditions that are not getting help. But they are showing up in medical settings. Being able to identify risk and then connect people to care, I think has been really important. It becomes about gap analysis because what that continuum needs to look like varies by community. Looking at all the communities that we serve and identifying who are the patients that are in need of behavioral health services, what’s available and how do we ensure that there’s a seamless continuum to connect folks with so within UCHealth. We’ve built out this continuum of integrated clinicians and psychiatrists. Within primary care, we have intervention on the emergency department side, the inpatient acute care side and we have inpatient psych, residential for substance use services, intensive outpatient programming — a lot of the traditional interventions. But then we also have looked at how do we get more upstream?
One of the programs that we have that I think does some of the most fabulous crisis intervention is our co-response program. In nine different communities across Colorado, we have relationships with the law enforcement communities. If you all know what the co-response program is, we partner with law enforcement to provide training for not only the law enforcement officers, but the dispatchers. So when a 911 call comes in, and it sounds like it might be behavioral health in nature instead of sending a traditional law enforcement officer, it’s the team of the law enforcement officer and the therapist who go out on the call. What we’ve found — we’ve had about 12,000 encounters — and over 90% of the time we avoid jail or emergency department utilization. We’re able to connect folks to care in the community. So it’s pretty broad. What that means to me from a continuing perspective, and I think we’re just continuing to do a gap analysis and make sure that we’re giving patients what they need, and potentially moving the needle on some of those statistics around suicide rates.
Olieth Lightbourne, DNP. Chief Nursing Officer for Streamwood Behavioral Healthcare System (Streamwood, Ill.): When you think about the continuum of care, you’ve first got to think about health promotion. As you think about promoting health, you think about partnering with community resources, partnering with schools and different things. When you think about health promotion, you want to think about health prevention. When you go to health prevention, you’re going to think more of population health, and what does that mental health community look like. We collaborate a lot with community providers representatives, so there’s shared access to care for those patients that have behavioral health composition.
You also want to think about acute inpatient where patients are stabilized. You really want to do a lot of promotion and prevention before you get to the acute phase. That’s where our hospital comes in. When patients are acutely ill and they’re presenting, we’re able to stabilize them. Then you want to think about recovery, whether you’re talking about substance abuse or depression, and you want to think about areas where you’re going to try to prevent recidivism before that occurs. When I think about the continuum of care, I want to focus more on promotion and prevention so we don’t have to get to those acute phases.
Becky Stoll. Senior Vice President of Crisis Services for Centerstone (Nashville, Tenn.):
Within our organization, the crisis continuum is really bucketed. It’s the operations of crisis call centers, including the 988, work that goes on for those calls and texts that cannot be handled via those methods. We have a mobile crisis footprint, and for those individuals that are seen in mobile you can provide resources, connect them with care and they can go home. Some people cannot do that, and they need the next piece of the continuum, which is facility based. That is walk-in centers, where people can walk in them with their loved ones to try to address whatever situation is going on.
The heaviest piece, the most acute piece, would be a crisis stabilization unit, where people can stay for three to five days and get the care they need. Within all of that, we really have to make sure we’re doing a comprehensive job of follow-up. I think in the past, we had not done as good a job as we should have. When people would touch the crisis system, we would work with them around what was going on, and then we would send them on their way. It’s an incredibly difficult system to navigate, and we often find that people are not in a mental health crisis because their bipolar disorder has come off the rails. It’s because life’s kicking them in the head.
We really need to make sure that we’re looking at the system as food banks and entities that provide diapers. It’s a much larger issue that people find themselves in, and we have a lot of gaps in that continuum. I think the crisis call coverage is pretty good. 988 is good. There’s pockets of the country that have little to no mobile capability, even worse, pockets of the country that have little to no facilities where people can walk in, or people can stay, or have the bandwidth to do follow up. Unfortunately, I think we have a lot of gaps that we’re going to have to have to look at state by state to really flush this continuum out and get people the help they need.
