Hospitals

Emergency rooms and inpatient psychiatric care

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Many individuals living with serious mental illness (SMI) do not adhere to outpatient treatment for a variety of reasons, increasing their risk for suicide and self-harm, violent behavior, substance misuse, insecure housing, high utilization of ERs, and frequent contact with law enforcement. These behaviors lead to high rates of inpatient psychiatric hospitalization and incarceration.

Assisted outpatient treatment (AOT) is a legal mechanism for providing outpatient treatment to individuals living with SMI whose non-adherence places them at risk for negative outcomes. AOT orders work by compelling the recipient to receive specific treatment that will prevent their condition from worsening and by committing the mental health system to provide treatment.

Emergency rooms

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Why does AOT matter to emergency rooms?

Emergency departments (ERs) have seen significant increases in admissions for patients presenting with mental health concerns. In Michigan, psychiatric emergencies were the most common reason for ER visits from 2017-2020. Patients admitted for mental health concerns stay disproportionately longer than other patients, often because of factors outside of the ER (such as limited inpatient beds). This results in an enormous financial burden to hospitals and limits capacity to provide other emergency services. In many cases, these increases can be attributed to frequent admissions of a small portion of patients with SMI in need of more sustained intervention.

Individuals may have a lack of awareness that their condition is a symptom of an illness that makes it challenging for them to adhere to outpatient treatment. This can lead to further decompensation and high utilization of ERs for healthcare. Thus, many of these individuals are more familiar to ER staff than community mental health professionals, creating a unique opportunity for ER staff to directly address the problem of high utilization by starting the process for AOT. Research has found that individuals on an AOT order have less frequent hospital visits, reduced suicidal and violent behavior, and reduced substance misuse.

AOT is designed to address the issue of non-compliance among individuals living with SMI, particularly those that cannot recognize that they are ill. Under Michigan law, the AOT process can be easily initiated  by completing the same form used for involuntary hospitalization (PCM 201 "Petition for Mental Health Treatment"). It can be submitted to the Probate Court for those being discharged home or sent along with the standard documentation for those being transferred to an inpatient psychiatric facility.

Action steps for emergency rooms:

  • Educate staff on patients eligible for AOT.
  • Adopt a process based on existing evidence to screen patients eligible for AOT.
  • Work with county Probate Court(s) to create a system to easily file petitions.
  • Identify a contact person within the community mental health authority(s) to assist in the tracking and monitoring of the AOT process.

Inpatient psychiatric facilites

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Why does AOT matter to inpatient psychiatric facilities?

AOT is designed to address the issue of lack of adherence among individuals living with SMI, particularly those that cannot recognize that they are ill. Under the current mental health code, individuals are eligible for AOT if their lack of recognition that they need treatment results in non-compliance and the likelihood that their condition will worsen, increasing the risk of harm (physical or mental) to themselves or others.

Lack of adherence can lead to decreased capacity to manage illness, worsening of symptoms, failure to connect to outpatient treatment, and thus frequent utilization of inpatient psychiatric care. Individuals can become dependent on costly care for their SMI needs, particularly those on Medicare who do not have contact with their community mental health until they have exhausted their benefits. Thus, inpatient psychiatric facilities are often the only mental health contacts many individuals have and the best opportunity for AOT to be initiated.

Research has found that individuals with an AOT order have less frequent hospital visits, reduced suicidal and violent behavior, and reduced substance misuse. Accordingly, using AOT as a tool to intervene with the individuals seen most frequently offers potential benefits to the inpatient facility and staff, including reduced readmission rates, increased patient safety, and improved employee retention.

Action steps for inpatient psychiatric facilities:

  • Educate staff on AOT, including identifying patients eligible for AOT.
  • Develop internal process for screening clients to identify who could benefit from AOT.
  • Work with the community mental health authority(s) to coordinate AOT implementation.
  • Identify community providers (such as CCBHCs and CRSPs) who offer common AOT services and establish liaison role.
  • Work with county Probate Court(s) to create a system to easily file petitions.
  • Identify a contact person within the community mental health authority(s) to assist in the AOT process.

 


Upcoming content

In the coming months, additional content pertaining to healthcare in emergency settings will be added to the toolkit, including training videos, a live webinar event, and testimonials. Contact us if you have ideas about information that should be included in the toolkit.

 

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