Children's Hospital Colorado was seeing kids with mental health issues affect its urgent care centers and emergency departments (ED) at locations across the state. In 2014, 92% of patients presenting to an ED or urgent care center in the hospital's network with a mental health complaint required EMS to transport them to the hospital's main campus ED. Half of those patients were then discharged home. "It was a complete waste in the system and a waste in expense for families," says Amy Lewis, M.S., RN, NEA-BC, director, Emergency Services, Children's Hospital Colorado. "This process increased length of stay, on average, 12 hours. It was the usual ‘we've always done it this way.'"
The hospital knew there was a better way to care for these patients. In 2014, a multidisciplinary group gathered to discuss the opportunities for offering tele-psych consults to the network of care in the ED and urgent care locations. The goals:
- Reduce unnecessary transfers.
- Decrease length of stay.
- Improve satisfaction for families and clinicians.
- Decrease cost.
- Ensure high quality care was provided.
- No poor outcomes.
Parameters of the program included excluding patients 18 years and older and those with out-of-control behavior, complex medical conditions, or parent or patient refusal.
Working through challenges
The group partnered with the organization's telehealth program manager to identify the equipment they'd need, and they worked to educate the ED and psychiatry emergency services teams. "We had some pushback from the ED and psychiatry teams at first," Lewis says. "We had a lot of discussion about the process, we practiced doing scripting, we practiced the introduction piece of not being in the room."
After seeing how volume affected caregivers' work, the hospital retrofitted rooms to make staff more comfortable. "That change spoke to staff that we were listening to them; and that we were thinking through how families perceive the care—didn't want them to feel the care was less than what they would receive at the main hospital."
For the hospital, it represents a new way of doing business. "With parental consent, we set up a tele-consult with the main psychiatry emergency services," Lewis says. "The patient tele-consults with a social worker, and he or she determines the patient's disposition. The patient is then discharged home, transferred to an ED or inpatient psychiatric unit, or transferred to outside mental health facility."
The program went live in 2015 and people started to buy-in and use the service. It was not mandatory at first, but it was presented as an option to families. "And it ballooned," Lewis says. "Two years later almost all the kids are getting their visit via telehealth."
In 2015, the hospital:
- Conducted 226 tele-psych consults.
- Decreased length of stay from 8.3 hours to 5.5 hours.
- Directly admitted 42% of patients.
- Reduced overall costs by $5,000 for each family for each visit.
- Didn't have any patients return for 72 hours within time of consult.
Continuing on the work
Since the launch, the hospital hired more social workers and has initiated tele-consults from the social workers' homes. This allows them to have additional availability. The program is also considering how to better serve non-English-speaking families. Ideally, the program would use live interpretive services, but these services are not always available, so they are sometimes conducted by phone. Communication with the IT team is also key. A group meets weekly with IT to tweak the system and ensure everything is working properly.
Overall, the tele-psych program is reducing costs, creating good outcomes for patients and saving time for providers and families.
