Improving Handovers in Mental Health Emergency Telehealth

Emergency departments (EDs) nationwide face numerous challenges, including the demand issue of many mental health patients and few mental health professionals to serve them. Emergency telehealth services have been tested and conducted for decades, often in Medicaid telehealth and safety-net settings. These emergency telehealth services typically involve a social worker, counselor, or psychologist using telehealth videoconferencing and intake software to conduct a structured intake with the patient in an ambulance or at a hospital, clinic, or other supervised healthcare settings. These professionals thereafter serve as a bridge between the patient in need of emergency care on the one hand and community professionals involved in transporting or delivering care to the patient on the other. In the case of a person who attempted suicide, the individual’s wounds are bandaged, but EDs usually require a qualified mental health prescriber to assess and admit or release the patient, which can require hours, days, and, in some documented cases, weeks. With the national shortage of psychiatrists, additional psychiatric staff can include medical psychologists and nurse practitioners. The shortage of providers has been recognized and addressed by the publication of emergency telehealth best practices by Telehealth.HHS.gov. The US Department of Health and Human Services (HHS) aims to impact future emergency preparedness and typical day-to-day emergency and acute care, particularly in telemedicine Medicaid.

How Emergency Telehealth Can Reduce Mental Health Delays

In crowded EDs, mental health patients are routinely kept on gurneys in hallways and nurses’ stations while awaiting admission or discharge by a psychiatric professional. As can be imagined, when unruly, such patients can significantly hinder the functioning of medical staff. These patients can require prolonged sedation and, in some cases, physical restraints.

Once assessed by the appropriately trained professional, these patients are either admitted or, more often, released on their own recognizance and referred to a community resource(s). Unfortunately, most such patients are unable to follow through. Simply referring patients to a local provider is rarely successful. The recidivism rate can be notable, particularly in hospitals in geographic proximity to community behavioral health organizations (CBHO). Patients leave the emergency facility of CBHO only to return in days, weeks, or a few months.

Emergency Telehealth Solutions

Emergency telehealth behavioral providers help to alleviate the complex challenges of hospital EDs, many of which struggle to find effective and humane ways of providing care to sometimes difficult-to-manage behavioral patients. Several emergency telehealth models have evolved. Some initiate contact with the patient through videoconferencing or telephone by a police officer or Emergency Medical Service (EMS) team. In other communities, the telebehavioral health social worker, counselor, or psychologist is requested in the ED, typically after medical discharge. In all models, emergency telehealth providers allow the patient to be more quickly seen and heard by a mental health professional.

Medical settings include urgent care centers, small community satellites, and large metropolitan or teaching hospitals on university campuses. Regardless of the size, most of these hospitals have overworked ED physicians and even more limited behavioral professionals on staff. Even before COVID, many behavioral patients would wait for a behavioral professional for an evaluation and discharge.

The remote provider then is expected to manage the video technology, interact and collect patient information, share that information with the hospital, and stay in touch with hospital staff. The remote provider may conduct a clinical, structured clinical interview, gather information, offer impressions, and make recommendations for aftercare.

According to the Medicare Telemedicine Snapshot, the process of managing telehealth emergencies is still a troubling area where problems can routinely occur. Communication breakdowns or errors in the delicate shift between behavioral health providers and the emergency room staff can lead to patient harm.

Behavioral and other providers must perform three duties at the end of a Medicaid telehealth visit involving potential harm to self or others, including the following:

• Ensure that emergency services know when a client has threatened self-harm or to harm others.
• Provide written and verbal communication to other healthcare providers.
• Check to see if any unattended issues still remain before considering the handover to be complete. 

Staff Training for Emergency Telehealth: Telemedicine Medicaid

To make the process manageable, behavioral practitioners working to assist hospitals with behavioral intakes may consider staff telehealth and telemedicine Medicaid training to develop the specific clinical and technical skills needed. Professional development may need to focus on allowing providers to learn the nuances of building a collaborative relationship with hospital staff. They may also need to learn how to set expectations of the providers at the hospital or any satellite sites. Logistical issues to address also include telehealth patient screening for appropriateness, fees, responsibilities of all involved parties, disposition of patient records, who is responsible for which parts of the documentation, protocols for sanitizing equipment after use, and handling the informed consent process.

Sample Workflow

While different scenarios are required in different settings, workflows will usually involve these steps:

1. The spoke team initiates a call to the hub while they provide immediate care.
2. The hub team answers the call and discusses the patient’s details and the level of support needed.
3. The hub team connects via video platform to interact directly with the patient and spoke team.
4. The spoke team relays information to the hub team and performs procedures.
5. Both teams discuss further treatment if transfer or transport is needed and finalize documentation.

Risk Mitigation in Telemedicine Medicaid Handovers

Healthcare providers can improve patient outcomes and lower liability in an emergency handover by keeping a record of the visit, either video or audio, and written evidence of the instructions given. Most importantly, the healthcare worker must contact the correct Public Safety Answering Point (PSAP)and impart clear, concise, and immediately actionable information. PSAPs have been organized throughout many rural areas to receive 911 calls and process those calls according to a defined operating policy. They are similar to call centers but are dedicated to answering emergency phone calls and dispatching help as needed. Locating the patient’s municipality can present problems, but modern technologies now provide healthcare workers with the tools to efficiently transfer Medicaid telehealth patients to emergency services.

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