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All too often, patients in psychiatric crisis end up in a hospital emergency room where they have to wait sometimes for hours to receive care.

Once there, they get checked out by doctors and nurses and often wait to either receive treatment, sometimes resulting in admission to psychiatric department, or get discharged to go home.

With that in mind, Billings Clinic announced Monday that its Clinic Classic fundraiser would go toward expanding its psychiatric department while building a new psychiatric stabilization evaluation unit that would get patients out of the emergency department and in front of psychiatric health workers who can better meet their needs.

"We would have a psychiatric emergency service that is designed for psychiatric patients instead of jamming those patients into a medical room in the emergency department," said Dr. Eric Arzubi, a child and adolescent psychiatrist and chair of Billings Clinic's psychiatric department.

Current process

As it stands today, somebody who visits the Billings Clinic ED with a mental health issue — an occurrence so common that there's a pod there designated for psychiatric patients, if room is available — first gets triage care in the entry room to determine their degree of urgency and is then assessed for any pressing physical medical issues.

From there, staff tries to determine more about the problem that brought the person to the ED in the first place and, if deemed appropriate, orders a psychiatric assessment clinician evaluation. Once that evaluation is completed, the results are used to determine if the person should be admitted to the psychiatric department across the street.

But it's a process that can take hours, especially when ED staff gets busy with more and more patients. It can leave patients upset and getting agitated from waiting, because they feel scared or uncomfortable or because they feel they're not being helped.

"To have people sitting in the ED for eight to 10 hours waiting for care just isn't acceptable," said Melinda Truesdell, a nurse practitioner and member of the clinic's PAC emergency team who works in the emergency department. "That's on the higher end, but it's not unusual to see a four- or five-hour wait. A lot of times now, the patients that we get are actually escalated by the environment."

She said that on an average 12-hour night shift, she might see six to eight people who come in suffering from a mental health crisis.

In addition, the ED rarely if ever fills prescriptions for such patients, even if that's what they came for in the first place. Those who are discharged are usually given a list of resources in the community for further help.

"We do things in our ER for psychiatry better than most places," Arzubi said. "We’re far from perfect, though, and there’s a million things we could be doing better. We are very aware of how long it can take, and we hate that it takes so long."

Improvements

The stabilization and evaluation unit is being designed to improve on many of those things.

The clinic's ED has seen a steadily growing number of PAC evaluations — from 3,653 in the 2014 fiscal year to 3,898 for 2016 — and many of those patients would likely end up in the new unit.

Based on what is called the Alameda Model — developed by Dr. Scott Zeller, chief of psychiatric emergency services at Alameda Health System in California — the unit will be a part of the psychiatric department, which sits across the street from ED.

Based on Zeller's model, instead of a hallway or two filled with individual clinic rooms, the unit will feature an open space where patients can stay and receive treatment for up to 24 hours.

In place of traditional beds, it will have chairs that can fold back into a sleeping unit as well.

But the aspect that has psychiatric staff most intrigued is that it's designed to allow patients to get out of the ED and into the new unit much more quickly.

"It will hopefully make it easier for the patients to relax and engage in whatever their treatment plan is," Truesdell said.

While patients might still start in the emergency room, the idea is that they wouldn't stay for too long. Instead, after receiving a physical checkup to make sure there aren't other pressing issues, they would come to the psychiatric stabilization evaluation unit, where Arzubi said they'd be seen by a doctor and nurses within 15 or so minutes.

Once there, patients can get help from psychiatric staff with medications, treatment courses or other needs and, if necessary, can be moved to inpatient treatment in the department's 44-bed psychiatric treatment facility.

The Alameda Model isn't widely used, but has been gaining traction for its successes. A study published in the "Western Journal of Emergency Medicine" in 2013 noted that it can reduce the length of boarding times for patients waiting for psychiatric care by as much as 80 percent.

In the study, which looked at numbers at a handful of centers in California, the average time in the ER for psychiatric patients was more than 10 hours, compared to just less than two hours with the Alameda Model. It also helped stabilize as many as 75 percent of the patients in mental health crisis, meaning they avoided inpatient stays.

"We can reduce unnecessary hospitalizations, but we can also stabilize them if they need it and get them quick access to a psychiatrist," Arzubi said.

Continual care

For those who do end up needing more help and are admitted for inpatient care, they can be transferred quickly and easily, since the stabilization unit sits alongside those services in the main psychiatric department building.

Patients in the acute inpatient unit — which has 44 total beds and sees an average of eight pediatric patients and 24 adults on a given day — stay for an average of three to five days while receiving treatment, said Carol Christensen, manager of the psychiatric center.

While there, patients undergo both group and individual therapy while also working on individual treatment plans and generally adhere to a carefully planned daylong schedule that leaves little uncertainty about the day's activities.

"People have this misconception that when you're here, you're here for a long time," Christensen said. "But those kinds of cases are really the outliers. When people come here, it really is a crisis-driven situation."

The hope is that some of those stays will be eliminated all together and free up more beds in the process with the new crisis stabilization unit, by addressing needs and getting the right help to patients in crisis more quickly.

"When you're chronically mentally ill, it takes a village, and sometimes in the village, there's vacancy problems," Christensen said. "Some people come here because this is where they get their needs met. That is a benefit, and that is a problem. We can't be the end-all, be-all for all people."

Even with Billings' robust medical community, officials have said more mental health resources are needed to meet the growing needs of the population, especially in light of a shortage of psychiatric workers.

John Felton, president and CEO of RiverStone Health, said that the unit could make it easier for his organization to follow up with its clients on a primary care basis and that it could play a role in filling a glaring gap in mental health care in the area.

"It just gives us and every other provider and first responder in town one more option to solve a problem," he said. "These are often very complex cases and issues."

Among other the services, the Mental Health Center in Billings provides outpatient psychiatric services that include evaluations and medication management, along with some emergency services on an on-call basis.

Executive Director Barb Mettler said that there's a lot of patient crossover between the center and the clinic and that, given the psychiatrist shortage, it could help with providing continual care for people who need it.

"I think we have a real need for something like that here," she said.

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