(PO-164) (PO-164) Emergency department discharge TO CARE (Telephone Outreach: Connect to Aftercare & Risk Evaluation): Improving patient care and systems-based practices

Emergency Department Discharge TO CARE (Telephone Outreach: Connect to Aftercare & Risk Evaluation): Improving patient care and systems-based practices.
Background/significance: Emergency department (ED) utilization is rapidly growing nationwide, with psychiatric concerns constituting 4.45% of annual ED visits (Hooker, 2019) and representing significant costs (Karaka, 2020). When compared to ED patients receiving outpatient referrals for medical conditions, ED patients receiving referrals for psychiatric care are more likely to reach an answering machine, to obtain an appointment >2 weeks away, and/or to be referred elsewhere for insurance reasons (Knesper, 2010). Studies investigating the effectiveness of follow-up contact post-ED discharge for patients presenting with psychiatric concerns are limited. 


Methods:  Patients seen by the embedded ED Psychiatry service (led by C-L Psychiatry faculty) agree to post-discharge follow-up contact during ED visit. Dedicated ED psychiatric social worker (SW) calls patients 48-72 hours post-discharge for a total of 3 attempts. SW asks protocolized questions regarding outpatient follow-up, medication status/adherence, and suicidal ideation (PHQ-9 Question 9). For a positive suicide screen, further questions including access to lethal means, crisis resources, and need for welfare check are pursued. 


Results:  Between 2/1/21-9/10/21, 711 patients were seen by the ED Psychiatrist and/or the ED Psychiatric Social Worker. Of this patient cohort, 475 patients were eligible for our follow-up protocol; 75 of these patients could not be contacted, the majority of whom (n = 45, 60%) had no working phone. 219 patients (55%) were successfully contacted, 59% of these (n = 129) on the first call. 63.5% (n = 219) had initiated contact or scheduled an appointment with an outpatient psychiatric clinic at the time of contact; of the remaining 80 patients, 72.5% (n = 58) expressed their intention to follow up with recommended treatment. Out of the group that was successfully reached, 86 had received prescriptions for medications upon discharge from the ED. 67% (n = 58) reported filling those prescriptions and noted treatment adherence.      


Discussion:  This embedded ED psychiatric service and protocolized discharge follow-up process eliminates barriers to accessing expeditious psychiatric care, assists in connecting patients to appropriate outpatient resources, and encourages patients to remain engaged in treatment. Future research and quality improvement directions will include examination of ED readmission rates as well as well as development of an alternative contact workflow for patients without working phones.
Conclusion/implications: This data adds to a limited evidence base to support continued integration of multidisciplinary Psychiatry teams into medical care settings, in this case, Emergency Departments. As ED resources are progressively strained, there is a growing focus on addressing population health factors. Reducing barriers to accessing psychiatric care, bolstering quality and efficiency of safe psychiatric care, and optimizing resource distribution should be top priorities for Psychiatrists working collaboratively in these settings. 


References:
Hooker, E. A., Mallow, P. J., & Oglesby, M. M. (2019). Characteristics and trends of emergency department visits in the United States (2010–2014). The Journal of Emergency Medicine, 56(3), 344-351. doi: 10.1016/j.jemermed.2018.12.025
Karaca, Z., & Moore, B. J. (2020). Costs of Emergency Department Visits for Mental and Substance Use Disorders in the United States, 2017: Statistical Brief #257. In Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Agency for Healthcare Research and Quality (US).
Knesper, D.J., American Association of Suicidology, & Suicide Prevention Resource Center. (2010) Continuity of care for suicide prevention and research: Suicide attempts and suicide deaths subsequent to discharge from the emergency department or psychiatry inpatient unit. Newton, MA: Education Development Center, Inc.