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Emergency department visits for anxiety, mood, psychotic disorders

4,3122018

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Story Behind the Indicator

The "Story Behind the Curve" helps us understand why the data on emergency room visits for mental health concerns is the way that it is in our community. When we understand the root causes of our community problems, we have a better chance of finding the right solutions, together.

What's Helping? 

Community members who participated in the planning meetings reported the following positive forces that influence this issue in a positive way in Transylvania County:

  • Access to RHA Mobile Crisis response can address concerns and create connections to appropriate care instead of an emergency department visit
  • Mental health treatment is available within the county; providers include Meridian Behavioral Health Services, Blue Ridge Health Center, Fresh Start at Transylvania Regional Hospital, and private providers
  • Education of primary care and specialty healthcare practitioners can identify mental health concerns and lead to appropriate treatement outside the emergency department
  • Partnerships with law enforcement can help people access appropriate care and avoid the emergency department
  • Cost and transportation can be barriers that prevent people from accessing any care for mental health crisis, including the emergency department
  • Family support and peer support can prevent crisis situations 
  • A behavioral health social worker is available in the Transylvania Regional Hospital emergency department 3 days a week to assist with connections to appropriate care and prevent repeat crisis visits

What's Hurting? 

Community members who participated in the planning meetings reported the following forces that influence this issue in a negative way in Transylvania County:

  • There are limited options for long-term mental health care and support in Transylvania County and the larger area
  • Existing policy limits EMS transport to the emergency department and does not allow transport to mental health facilities, which are located outside the county
  • Many people are not aware of the mental health resources that do exist in the county such as Meridian, RHA Mobile Crisis, and local providers, or how they can access care through these resources
  • Stigma around having a mental illness and perceptions of mental health treatment creates a barrier to requesting needed care
  • People do not feel comfortable accessing care
  • Ongoing mental health problems are not addressed until they are at crisis level
  • Cost and transportation can be barriers that prevent people from accessing care for mental health concerns until they reach a crisis level
  • The prevalence of adverse childhood experiences contributes to the presence of mental illness and creates barriers to accessing care
  • Some people lack information and understanding about what mental health looks like; living with undiagnosed mental illness may be "normal" for some people
  • A lack of social support and peer support lead people to seek care in the emergency department for mental health concerns
Partners with a Role to Play

Partners in our Community Health Improvement Process: 

The following individuals and agencies were represented in the planning process related to emergency department visits for mental health concerns:

  • CARE Coalition
  • Davidson River School
  • Fresh Start at Transylvania Regional Hospital
  • Lutheran Church of the Good Shepherd
  • Meridian Behavioral Health Services
  • Transylvania County Government
  • Transylvania Public Health
  • United Way's TRAIN (Transylvania Resource Access and Information Network)
  • WNC Healthy Impact

Partners with a Role in Helping Our Community Do Better on This Issue: 

The following organizations were identified as potential partners on strategies that were considered during the planning process:

Government agencies

  • City of Brevard
  • Transylvania County
  • Transylvania Public Health
  • Law enforcement: City of Brevard Police, Transylvania County Sheriff
  • Veteran’s Administration
  • Transylvania County Vocational Rehabilitation
  • Transylvania County Department of Social Services
  • Transylvania County Library

Healthcare providers

  • RHA Mobile Crisis
  • Meridian Behavioral Health
  • Transylvania Regional Hospital
  • Blue Ridge Health Center
  • Transylvania County EMS
  • Private mental health providers
  • VAYA
  • MAHEC

Non-profits

  • SAFE Inc.
  • The Haven
  • Sharing House
  • The Family Place
  • The Children’s Center
  • CARE Coalition
  • Child Advocacy Center
  • CONNECT
  • El Centro Hispano
  • United Way
  • MountainWise

Businesses

  • Business owners
  • Brevard Rotary
  • Pisgah Forest Rotary

Schools

  • Transylvania County Schools
  • Brevard College
  • Blue Ridge Community College

Others

  • NAMI
  • AA and NA
  • Churches
  • NAACP Health Committee
  • Pisgah Health Foundation / Dogwood Health Foundation
Strategies Considered & Process

Actions and Approaches Discussed by Our Partners

Our community partners considered ideas of what works to do better, what is currently working in our community, what people most affected by the issue think will work, evidence-based strategies from sources such as the CDC, County Health Rankings, and Healthy People 2020. The following actions were identified by community members as ideas for what can work in Transylvania County to make a difference on reducing emergency department visits for mental health concerns:

  • EMS transports directly to mental health treatment as modeled by other North Carolina counties
  • Use of mobile crisis services
  • Access to long-term case management
  • Peer support bridge programs
  • Walk-in recovery education at Meridian
  • Behavioral health crisis walk-in services at Blue Ridge Health Center
  • Behavioral health professionals available in emergency department
  • Mental health crisis care location within the hospital but outside the emergency department
  • Outpatient mental health programs like Fresh Start
  • Education to improve knowledge about existing resources in community
  • Education to improve knowledge about mental health concerns, symptoms, and when to seek care
  • Education to improve knowledge about how to access mental health services
  • Trauma-informed care training and certification for healthcare professionals and others in the community
  • Healthcare professionals conducting regular screening and referrals to mental health services as needed
  • Availability 24-hour warmline via phone and/or text for short-term support to avert crisis situations
  • Availability of non-medical respite care to avert impending crisis as modeled in Atlanta area

Evidence-Based Strategies 

In addition, the following evidence-based strategies are actions and approaches have been shown to make a difference on reducing emergency department visits for mental health concerns, from resources such as the CDC's Community Health Improvement Navigator, the CDC's The Community Guide, County Health Rankings, and Healthy People 2020.

Name of Strategy Reviewed

Level of Intervention

Changing regulations for mental health insurance coverage to improve financial protection and to increase access to and use of mental health services including substance abuse services

Policy

Clinic-based depression care management for older adults with major depression or chronic low levels of depression

Individual, Organizational

Home-based depression care management for older adults

Individual, Organizational

Collaborative care for the management of depressive disorders

Individual, Organizational

Screening for depression in the general adult population

Individual, Organizational

Individual cognitive-behavioral therapy for symptomatic youth who have been exposed to traumatic events to reduce psychological harm

Individual

Group cognitive-behavioral therapy for symptomatic youth who have been exposed to traumatic events to reduce psychological harm

Interpersonal

Chronic disease management (CDM) programs to improve quality of life for patients with mental health issues

Individual, Interpersonal

Cultural competence training for health care professionals

Individual

 

Process for Selecting Priority Strategies

Community members first identified several root causes or pieces of the "story" that they believed would be most important to address, from their own personal perspective or the perpective of their represented agency. They then identified up to two strategies (either discussed above or others that they had knowledge of) that would significantly impact that particular root cause.

They also indicated if they or their agency would be willing to lead, collaborate, or support each suggested strategy. Strategies with identified leadership are bolded below.

  • Increase mental health knowledge in the community for family members, churches, primary care providers
    • NAMI classes e.g. Family to Family
    • More comprehensive listings on 211
    • Media campaign
    • Psychiatric consult service for primary care professionals to help with medication adjustments (offered to Mission-affiliated physicians)
  • Increase knowledge about mental health resources
    • Screening and referrals to mental health care by health care professionals
    • Get Set and Sesame Street toolkits for difficult conversations
    • Track and promote existing resources in community
  • Reduce stigma
    • Education for family and friends
    • Small groups for mental health education, self care, etc.
    • Outpatient programs
    • Mental health care outside emergency department
  • Improve social and peer support for those diagnosed with mental health issues
    • Respite care
    • Bridge support
    • Peer support in emergency department
  • Increase access to services
    • Peer bridge program
    • Outpatient programs
    • Long-term case management
  • Increase resources within emergency department
    • Education for emergency department staff on trauma-informed practices and suicide prevention
    • Peer support in emergency department
  • Follow up after ED visit for mental health concerns
    • Peer support programs
    • Emergency department policy on number of days for follow-up appointment to be set
    • Outpatient programs
    • Screening and referrals by healthcare professionals
    • Behavioral health professionals in emergency department
    • Hospital having planner who follows patients after discharge / case management
    • Trauma-informed care training for providers
  • Improve long-term care and support
    • Walk-in recovery education
    • Screening and referrals to mental health care by healthcare professionals
    • Peer support programs for education, respite, social support, hotlines and warmlines
    • Long-term case management
    • Recruitment of additional mental health professionals
  • Increase mobile crisis usage
    • Media campaign for mobile crisis service: advertise on billboard, card in public spaces
    • Educate law enforcement and other community partners about mobile crisis option
  • Create and encourage options for diversion from emergency department
    • Step-down from psychiatric admission
    • Outpatient programs
    • Long-term case management
  • Build partnerships with community providers (e.g. law enforcement, first responders, providers) to provide better care for mental health concerns
    • EMS and law enforcement able to transport directly to treatment
    • Trauma certification for law enforcement and EMS
    • Partner education about existing resources
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