Afternoon, everyone, and welcome. I'm Dr. Terry Brister. I'm the Chief Program Officer at NAMI, the National Alliance on Mental Illness, and also the Individual and Families Expert for SMI Advisor. I'm pleased that you're joining us for today's SMI Advisor webinar, Empath Units, Improving General Hospital Behavioral Emergency Care. Next slide, please. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers that you need to care for your patients. Next slide, please. Today's webinar has been designated for one AMA PRA Category 1 credit for Physicians, one Continuing Education credit for Psychologists, one Nursing Continuing Professional Development Contact Hour, and one Continuing Education credit for Social Workers. Credit for participating in today's webinar will be available until January 13, 2024. Next slide. The slides from the presentation today by Dr. Zeller are available for download in the webinar chat. And if you select the link, which just went in the chat, you'll be able to view those. Next slide. Captioning for today's presentation is also available. If you click Show Captions at the bottom of your screen, it will enable the caption feature. Click the arrow and select a view full transcript to open the captions in a side window. Next slide. Please feel free to submit your questions throughout the presentation by typing them into the question area that's found in the lower portion of your control panel. We'll have 10 to 15 minutes at the end of Dr. Zeller's presentation to be able to take your questions. And I'll be collecting those during the presentation and then sharing them with him on the other side of the presentation. Next slide, please. And now it is my great pleasure to introduce you to the faculty for today's webinar, Dr. Scott Zeller. Dr. Zeller is Vice President for Acute Psychiatry at the multi-state, multi-specialty physician group partnership, FITUITY, Assistant Professor at University of California, Riverside School of Medicine. He's past President of the American Association for Emergency Psychiatry. He's past Chair of the National Coalition on Psychiatric Emergencies and former Chief of Psychiatric Emergency Services for the Alameda Health System in Oakland, California, where he developed the Alameda model. He's known as the co-inventor of emergency telepsychiatry and the creator of the EMPATH unit, Emergency Psychiatry Assessment, Treatment, and Healing unit, model for behavioral health emergency care. He led Project Beta, Best Practices in the Evaluation and Treatment of Agitation, which produced guidelines that have revolutionized the care approach to agitated individuals around the world. I've had the privilege of hearing Dr. Zeller's presentation on this topic, and I'm excited that he's joining us today to continue to raise awareness on the EMPATH model and the need for all of us to look at our practices in terms of treating people experiencing psychiatric emergencies. So Dr. Zeller, thank you for being with us today. Thank you very much, Terri. It was a very kind introduction. And we'll go ahead real quickly with the learning objectives, which you can see here on the screen. And these are going to be self-explanatory as we move forward. So let's go ahead and get going. Talking about EMPATH units, as Dr. Brister so kindly introduced us on, we're talking about EMPATH units as a solution for emergency care for psychiatric patients traditionally ending up in hospital emergency departments. And so before we even get too far along, I wanted to open up by kind of defining what we consider to be a psychiatric emergency, because it may mean different things to different people. But I'm usually thinking of a psychiatric emergency, and these are folks who often end up in hospital medical emergency departments and are there because they're a bit too acute for anywhere else in the community, for other community or outpatient programs. And we can define a psychiatric emergency very simply as when someone, due to a behavioral health condition, is acutely a danger to themselves. And we can think of that as really the key part here is it's due to a behavioral health condition. For example, I have a friend who likes to jump out of airplanes on a surfboard. I think that person is an incredible danger to himself. However, according to a psychiatric emergency definition, he's not doing that according to a behavioral health condition, as far as we know, anyway. So we're not going to hospitalize him because he's jumping out of an airplane on a surfboard. So there's a difference between just being dangerous to yourself and being dangerous to yourself as a psychiatric emergency. Very similarly, with a danger to others, somebody who is maybe like a organized crime hit man, we could conceivably say that person's a danger to others, but they're not doing it because of a behavioral health condition. So that's not a psychiatric emergency. We'd also include under psychiatric emergencies what sometimes is terminology called a gravely disabled state. When somebody is due to that site condition, is so impaired, they cannot provide for themselves in terms of food, clothing, or shelter. Or if those things are offered to them, they can't take advantage of it. For example, if you said, here, you're starving. Here's some food. And they say, I'm not eating it. It's poison because of a delusion, that would be a psychiatric emergency. Or really, when anybody appears to be at risk to involve one of those conditions. So now that we've kind of got those parameters, we can take the next step and discuss a little bit more of what the problem to solve for today is. So I mentioned at the outset that there's a lot of patients who are coming into general hospital emergency departments with those psychiatric emergencies and behavioral health emergencies, as we just defined. There's about 5,000 general hospital ERs in the USA. And right now, as of us speaking, they're averaging somewhere between 12% and 15% of the patients they see are there for a behavioral health emergency. And we're talking about millions and millions of patients coming in to hospital ERs with these behavioral emergencies. And we've seen the numbers rise dramatically since 2020. Key thing to remember when these folks are going to emergency departments is that, according to the federal government, according to EMTALA, psychiatric emergencies are medical emergencies. They're psychiatric emergency medical conditions. So when those of you familiar with EMTALA, EMTALA is a federal law that if you are within 250 yards of a hospital campus with an S&ER, and you are seeking emergency care for an emergency condition, that hospital has to evaluate you without regard to your ability to pay to determine whether or not you have an emergency condition. And if you do, they have to either stabilize you or admit you to an inpatient unit. And so that applies to psychiatric emergencies as well. And when you're starting to talk about the number of patients coming in being 15% of your patients, that might be more than the people who are coming in with chest pain or flu symptoms or abdominal pain or after a car accident or something like that. And if you had an increase in any of those other conditions, I think your hospital would probably make an effort to do a much better job taking care of those folks. So it's really way past time that there's an understanding that psychiatric emergencies are a major component of the patients going to ERs, and that hospitals really need to address this and not just keep crossing their fingers and clicking their heels and hoping that these psych emergencies are going to go away. They really need to start preparing for these and come up with great solutions, algorithms, and preparation to deal with these folks when they come in with these very debilitating and traumatizing emergency conditions. But what has happened instead? For about the past decade or so, we've seen the focus on solving the number of patients coming to ERs as being what's often called upstream solutions. And the idea is that if we can just offer more crisis alternatives, if we can have crisis counseling drop-in centers, if we can have mobile crisis teams, if we can have crisis intervention facilities, if we can add crisis concepts to community behavioral health clinics and other places, these are all fantastic ideas. They're wonderful ideas, and they're really good things. And all these things should be moving forward, and all these programs are wonderful and worth their weight in gold. There's only one problem. They're often pitched as, if only we have this one new program, nobody's going to have to go to the ER again, and we're not going to have anybody going to the emergency department. If you just fund this new program, it's going to solve the problem. And it's wishful thinking, unfortunately, because there needs to be an understanding about levels of acuity. Because as much as we've opened up all these wonderful programs, which are doing a great job and really helping a lot of people, at the same time, the number of behavioral health patients coming to hospital ERs during that past decade has only gone up, and it's gone up substantially. It's not even like an error when you're doing research, so the slight thing is the confidence level's way, way up. The numbers continue to go up, up, up, and are now one in every seven patients in a hospital ER across the USA is there for a psychiatric medical emergency. And those stays are lasting a long, long time, usually far longer than any other non-psychiatric medical emergency. They often can average over 30 hours. Recently, I've been talking to different hospitals where their average length of stay for psych patients in their ERs is over 50 hours. Imagine that, that's longer than two days. That's their average. It's not an outlier. It's not the occasional patient. This is like every person they're seeing is staying on an average over two days. That's an issue. The good news has been is that we've seen hospitals all across the USA, which has been wonderful, and again, Canada as well, who are no longer saying, gee, we need to find a program upstream. We need to find a community program to solve this so that these patients don't come to us anymore. They're starting to say, you know what? EMTALA says these are emergency patients. We should say these are our patients. There are patients too, and we should treat these folks and evaluate these folks the same way we would do if somebody came in with chest pain, if somebody was in a plane crash or auto accident, and we should make sure that we're treating these folks with this emergency condition the same way we would do any other medical emergency, and we should not think of what we might call crisis care or psychiatric emergency care. That should not stop at the edge of the campus. It should not stop at the emergency department door. We should be doing this. We're part of that continuum, that acuity, different levels of care that makes for a whole spectrum of mental health care within a system. So why hasn't the crisis system been able to prevent these folks from going to the ER, and in fact, that we've seen this dramatic rise in the number of patients coming to the ER? In fact, from about 15 years ago to about six years ago, the number of people coming to hospital ERs in the US for reasons around suicidality went up over 400%. I mean, that's how many people are coming to ERs. This is not something you can just go, oh, yes, I sent my patient there, or the occasional person goes there. No, this is a huge, huge thing. Tons and tons of psych patients go to hospital medical ERs, and so we've set up these alternative programs. Sometimes they're called alternative destinations, crisis receiving centers, crisis facilities, community crisis, mobile crisis, crisis residential, crisis intervention. Wonderful programs, as I said. Why aren't they keeping people out of the hospital ERs? Well, for one thing, they tend to be set up for ambulatory, high-functioning, mild to moderate severity patients. People who come in and say, hi, I'm going through a personal crisis. Do you have someone I can talk to? Yes, oh, fantastic, you're here. Here's somebody you're gonna see right away. It's great, we're gonna help you out. They might have people who are under case management or partial hospitalization programs. Wonderful, wonderful things, as in, nothing against these programs. They do wonderful work, but what happens is, what happens if somebody, for example, comes in and says, I want to kill myself, and I just took a massive overdose of medications? You're not gonna stay at the counseling center. If you've just taken a massive, we're not gonna have you stay and talk to somebody. If you've got all this poison in your system, we're gonna call 911 and get you to that hospital ER. And that's basically the situation. If you're set up for mild to moderate, when the emergency patients come in, they still go to the emergency department at the hospital closest by. You may call 911. You may have the person who brought them in say, hey, you gotta get them over there. But it's not just those really obvious patients like overdose. It may be anybody who comes in who's loud, screaming, agitated, aggressive, or you know has a history of being violent when they're having acute symptoms. They might be floridly psychotic with symptoms of psychosis. They may be so suicidal that you need to have somebody on a one-to-one with them. Maybe somebody who they just took a gun out of their hands who was trying to point at themselves. Somebody who just talked off of a ledge. If people are coming in who have comorbid substance abuse issues, somebody who might be seriously intoxicated or in serious withdrawal, which is a highly acute medical condition. And if they're involuntary, that's another huge, huge thing. Most community programs can't work with involuntary patients, which when you get to high acuity, a lot of folks end up being involuntary. And then if you have any other medical comorbidities up to and including if you have a diabetes and you have a rainbow insulin coverage, that might be beyond the capabilities of these programs or even just basic vital signs abnormalities. So when we're thinking of all this, just realize, again, these programs are doing great work, but you would not open up a medical urgent care in the Walgreens in your community and say, okay, great, now we can close our trauma center because you need different levels of care. You hope to be able to help people who are having certain levels of care in alternatives to the hospital. But when somebody gets that high emergency, that high acuity, they end up going to the ER just like they would if they were in a car accident or they were having a heart attack. There's another issue that comes in with this. And that's when we've been talking a lot recently about equity and parity. And what we find is, is that we look at different communities and where they would go if they have a psychiatric emergency. We find that minority communities tend to go to the ER as their first thought, where do we go? Especially black and Hispanic adults at that very young adult stage between 18 and 44, they were far more likely to go to the ER than anywhere else if they had a mental health concern, not even just emergency, they're gonna go to the ER. And then if you would go black and Hispanic men of all ages are gonna go to the ER. So should we do our best to educate and inform and market the availability of alternatives to hospital ER for these communities? Absolutely, that should be a priority. At the same time, we shouldn't just say, we're trying to tell them all they should go somewhere else so we'll meet them at the door and tell them to go somewhere else. No, these folks are coming, by federal law, they have a right to be seen. So we need to be prepared for them and we need to help them just as we would. And there needs to be no wrong door. If you're gonna be working with anybody in any kind of crisis, if they come to you, it should be open arms and how can we help you? And this may be the worst day of your life, let's help you get through this and we're gonna get you better in a safe and positive way. That's what emergency departments and hospitals do and they've done historically for many years. They've always accepted people regardless of racial, ethnic, sexual, gender, any other population. Everyone gets in need immediately and I think they've all done this voluntarily but federal law says they have to do it anyway. And that, as I said a few minutes ago, federal law defines psychiatric emergencies as medical emergencies. And so anytime that you would say, gee, these folks come to the ER, they should be going somewhere else. Why can't we get them somewhere else? That contributes to the stigmatism that we have around mental illness and thinking that somebody's not in the right place or they came through the wrong door or we treat medical or physical emergencies here and you're a mental emergency, you should go somewhere else. That's a horrible approach. These are all, the brain is part of the body too. If you're having a psychiatric emergency, that's a medical emergency. The federal government says that, I say that, hospitals should say that too and we should always accept everybody with no discrimination and help them as much as we can to the best of our capability and that's how we're gonna eliminate a lot of the stigmatism and at the same time, get much happier and healthier outcomes. But let's go to the downside of doing all those really good positive things. One of them is when mental health emergency patients, behavioral emergency patients come into the standard hospital emergency department, they have a much longer length of stay than other patients who come to the emergency department which is usually referred to as ED. So I'm gonna call it that from now on just to save time. Do you know what that is? ED, emergency department. They have a three times longer length of stay than any other type of emergency in the emergency department. That hurts the hospital because they could have turned that bed over two and a half times. So they could have helped a lot of other people in their waiting room but they couldn't because that bed was taken up with that psych emergency patient. This has led to a concept called boarding where patients are stuck in the ER sometimes for long hours, sometimes for days waiting for transfer to a psychiatric facility. Hospitals have seen their role as we will do a medical evaluation. If you're otherwise non-psychiatrically medically okay, we'll refer you to a psychiatric hospital and you sit tight. And so they often have people sit there for long hours, often days and that phenomenon is called boarding. And when a hospital boards a patient, here's a number, this is from 2008. This is 15 year old number. It costs that hospital $2,264 every time that happens. That's $2,008. I've got to imagine that's well over 4,000. So if we're gonna try to actually change things in the emergency department, we need to look at some of these challenges. One is that we have this limited capacity to work with patients in the emergency department. It's leading to a lot of bottlenecks and throughput issues in the ED environment, which is not set up for behavioral emergency patients in the first place. The emergency departments are set up for heart attacks and trauma and people with active bleeding and broken bones and setting up an environment for that kind of population is way different for somebody who's having acute paranoia or psychosis or is acutely suicidal. So it's a really different environment. And what we know is that the standard ER environment, ED environment can actually make psych patient symptoms worse. They are claustrophobic, they're confining, they can feel like punishment or prison, they're very noisy, they can be frightening, they're scary. And these can actually make patient symptoms worse. At the same time, the emergency department doesn't have the right personnel to really work with this population because they mostly have people who are really good at heart attacks and broken bones, not quite as familiar in most cases with working with people with acute suicidality, psychosis, what have you. This can lead to problems with safety overcrowding and goes back to like what I mentioned a few minutes ago, which is our role is to make sure that their blood pressure is okay, they're ambulatory, they're not having a heart attack and now we're just gonna hold them until we can get them to a psych hospital. That's what's causing this thing called boarding. And unfortunately, what most often is happening with boarding is what you kind of see in this picture, which is people sitting in hallways strapped to gurneys, sometimes for long hours, sometimes for days, sometimes for even weeks, waiting for transfer to a psychiatric hospital. And unfortunately, during this time, they're usually getting zero treatment, which if you can imagine if you came in with already bad psych symptoms and you're strapped to a gurney in a hallway, and the only time you even see somebody is once a shift, they take your blood pressure and maybe bring you a food tray or something like that. And you're not in any treatment. If you had bad symptoms, there's a good chance that they're actually gonna get worse while you're there. And the environment itself is gonna make them worse, but everything else, the end, the lack of treatment is gonna even make it that much worse. And then it also leads to overcrowding of the emergency department, which comes with a lot of bad outcome and the different metrics. And it's getting worse because as I think most of you who are familiar with, we're having a major mental health crisis that has evolved as we've come out of the pandemic. On top of that, we have seen something that has been an amazing and one of the most positive things in acute and emergency psychiatry to happen in my career, I would say, and that is the offering now that we have a three digit hotline nationwide for people to call when they're having a behavioral health emergency. It's 988 and it replaces what used to be the 1-800-273-TALK, which did amazing work, the National Suicide Prevention Lifeline. But you can imagine if you're at wit's end and it's just the worst moment of your life and you're ready to kill yourself and you're thinking, I can reach out for help and what's the number? 1-888-CARS4KIDS. I don't know, you can't remember it. And so 988, I think everybody can remember that. It's close to 911. I think if you've even called 911, they could tell you about 988. It's a great, great thing. It's such a wonderful thing. Here's the one issue though, when we've been talking about all these patients overwhelming the ERs, when we had that more difficult number to remember that 1-800-273-TALK, we were getting 40 million plus annual crisis calls across the USA. Now we've got a much easier to remember and easier to access number 988. And in the first year or so since this came out, since July over a year ago, we know that the numbers have gone up by over 50%. So instead of 40 million crisis calls across the USA, we're looking at over 60 million. And even if just a tiny, tiny, tiny percentage of those ends up going to hospital ERs, that's still increasing the numbers coming there. And that's a concern. And so that's, I'm sure, adding to the numbers overall where we're seeing one in seven and maybe even rising of every patient in ERs there for a behavioral emergency. So what have people suggested about this? One of the things that's been frustrating to me, I've been doing emergency psychiatry for over 30 years. And one of the frustrating solutions is that, so I've seen people do stories on CBS, NBC Network News or major publications like the New York Times, Washington Post, where they say, look at all these people waiting in these hospital ERs be transferred to a psychiatric inpatient bed and there's no inpatient bed available. Clearly the only solution is let's build a lot more inpatient beds. Let's send them all to inpatient beds and just build them more and more and get as many as we need. And that's a strange thing because we can build more inpatient beds and we probably should, because I think we're way under capitalized in terms of the number of inpatient site beds, no argument. At the same time, we can't just think of emergency departments as a pass through where people just go and we send them to the inpatient unit because that's not helping anybody and it's not really doing well by the patients. The example of the comparison I can give you is, let's say completely unrelated to psych but still in emergency condition. Let's say you have asthma and you're having a bad asthma attack and you can't breathe, can't breathe, please help. And you come to the ER and they meet you there and you say, oh, you're having an asthma attack. Please come with me. I've got a gurney to strap you down to in the back hallway of our hospital. We're gonna have you sit tight there until we can find an asthma hospital to transfer you to. We should be able to get you one in the next day or two and they'll be able to handle your asthma attack. No worries, keep breathing. We'll check in with you in a few hours. That sounds ridiculous, right? We'd never do that in an emergency department. In the ED, we would start a person on oxygen. We would give them a nebulizer. We would resolve that asthma attack probably within a few hours and that person would go back home to their family in that time. We can actually do the same thing with psychiatric emergencies, yet we only think that we need to do things this old-fashioned way. We're hospitalizing every patient with a psych emergency. That's the same as hospitalizing everyone who comes in emergency department who has chest pain. It turns out that only 15, 20% of the people coming to ERs with chest pain get admitted because a lot of them, turns out that's something they can resolve quickly. Sometimes it's just indigestion. Sometimes it's other things, but they can fix it in the ER because they pay attention to it right away and they treat it right away. And that's the big difference. What we've been doing wrong is just doing this pass-through. And these solutions are just, let's build more inpatient beds without the recognition that the great majority of psychiatric emergencies can actually be stabilized in hours rather than days. So if we wanna get rid of boarding in the ED, we should be making changes at that emergency level of care. And that's where we get to EMPath. And just before we go any farther, EMPath, I know it's a cool snazzy name, but it's not a brand name. It is not anything that's copyrighted or anything. It was actually created to be a generic academic acronym that anybody can use. If you say tomorrow, hey, at my hospital, I wanna create an EMPath unit, you can go ahead and do so. It's yours. It's a specific model of a hospital-based behavioral emergency care unit. And if you say you wanna do it, nobody could stop you any more than you would say, I wanna create a labor and delivery unit. EMPath is like saying labor and delivery. It's just a section of the hospital, but it's just a newer term. So some folks are unfamiliar with it. And so they weren't quite sure if it's okay to call it that. No, call it an EMPath unit. If you don't believe me, you can ask Wikipedia. They have a whole big section on EMPath units. So EMPath units, the name EMPath stands for Emergency Psychiatric Assessment Treatment and Healing. What's really neat about that is that it goes in the order of how we treat people in EMPath units. We assess them and we treat them. That's the big difference than what happens in ERs. Treatment starts right away and then healing occurs and we constantly reevaluate and check to see how people are doing and adjust our treatment so that hopefully we can help the vast majority of them avoid the need for inpatient care. So EMPath units are based on what are known as the six goals of emergency psychiatry, or sometimes in the literature, you'll actually see them referred to as Zeller's six goals. And what you may remember is that my name is Zeller as well. And the cool thing is, is that's because I wrote these. So it's kind of fun that they're known that way. But real quickly, we'll just go through these so you can understand how an emergency psychiatric unit, how an EMPath unit functions. The first thing is, is that we wanna exclude medical etiologies and really ensure that people are medically stable. Why is that important? Because based on the study you look at, anywhere from 10 to 25% of what appears to be psychiatric emergencies are actually medical emergencies. There's a lot of things that cause psychiatric mimic symptoms like poisoning or head trauma or withdrawal or other things that lead to confusion or psychosis. And we would never wanna have somebody who did head trauma and is actively having an intracranial bleed say, oh, they're just psych and have them go sit in the waiting room rather than have them evaluated right away. Unfortunately, there's some actual sad stories of that happening. And we don't really want to tell you about those outcomes. So what we do wanna have is just have a really good, quick medical evaluation. Let's make sure we get a good set of vital signs, look at people's skin, eyes, ability, ambulate, cognition. And then once we know they're otherwise medically okay, let's move them into an emergency psychiatric treatment. And then we want to rapidly stabilize that psychiatric emergency. Why is that such a big deal? Because too long we have thought of psychiatric emergencies as very low priority in emergency departments. Obviously people come in heart attacks, car crashes, whatever, they should be the top priority. And there should be other things that are bigger priority than psychiatric emergencies. But we shouldn't have them way down there below people with sniffles or somebody looking for directions to the cafeteria or something like that. They should be up there a bit higher up. And it's because these are true emergencies. People are actively suffering. And I've talked to my colleagues in emergency medicine and say, these are horrible, horrible suffering emergencies for these folks. This might be the worst day of their lives. They're in absolute agony. And they need help as quickly as possible, just like so many of these other, what we would call more traditional physical emergencies. And I have been told back by my colleagues, well, you make some good points, Scott, but here's the difference. We have x-rays that prove conditions in our physical emergencies. We got blood tests that prove these conditions. We don't have x-rays or blood tests for psychiatric emergencies. So how about that? And I will respond, yeah, you're right. We don't have x-rays or blood tests for psychiatric emergencies. You know what else we don't have x-rays or blood tests for? Pain. And yet when you come into the ER and say you're having horrible, excruciating pain, we believe you and we help you. And we empathize with you and we want to help you. We want to do it really quickly because we know how much severe pain is terrible. Well, maybe think of a psychiatric emergency as the worst headache in your life. And if somebody comes to you with a psychiatric emergency and their head is just suffering and there's so much pain, you want to help them. You understand it. Let's do it quickly. Let's get them relieved from that suffering. That's what we do. We're medical providers. Let's get them through this. They're going to be better. We'll get them through and then get them to that next level. And hopefully we're going to do it in such a way where instead of the traditional approach in emergency mental health care, where it's involved a lot of coercion, a lot of restraints, a lot of involuntary medication, a lot of shut up and sit down, do this. I'm the doctor, you're the patient. Instead of doing that, let's do a therapeutic alliance where we're, hey, you're going through a tough time. We're two humans. Let's get you through this together. And in doing that, we're going to treat in the least restrictive setting. That means changing the mindset of a lot of the folks of all we've been talking about before, where they think the best thing we can do for folks is get them to an inpatient hospital bed. But instead, you know, even those of us who work in hospitals and we think they're a nice place to work, would we like to be locked in there for the next week? You know, I think most people would rather be home, sleep in their own bed, be comfortable, be able to eat what they want, come and go as they please. That's the least restrictive setting, being locked into a hospital, and even worse, being in restraints or something like that. That's very restrictive. Let's go in that other direction and try to get people back home as much as we can. If there's a small percent of them that still need hospitalization, then let's get them hospitalized. But we shouldn't think that we're doing people a favor by hospitalizing them. That should be only when it's truly no alternative. Most of the time, we should be discharging them back home. And when we do so, let's do so with a really solid disposition and aftercare plan, so good that we can change our emergency patient into an outpatient, and hopefully they're not gonna get into emergency situation again, as we've set up good outpatient plan together. So as I said, that's what EMPath is all modeled around. Again, it stands for Emergency Psychiatric Assessment, Treatment, and Healing. And the amazing thing about EMPath is usually these are extensions of the ERs or psychiatric observation units that are adjacent or very close by the ERs, or sometimes a separate place, but still on the same hospital campus. You come in through the ER, the same patients who today would be boarding, waiting for an inpatient bed, we actually quickly move them to the EMPath unit. The same way, if you came into the ER at 3 a.m., because it's the only door into the hospital, and said, I think I'm about to have a baby, they'd take a quick look at you and go, yeah, I think so. Let's get you over to labor and delivery. The same way you do that, you do with EMPath. Hey, I'm having a psychiatric emergency. Sure looks like you're doing it. You're medically okay. Otherwise, let's not screw around. Let's move you right over to the EMPath unit. Very comparable to labor and delivery. It is the designated destination for all otherwise medically okay patients. And it's not an alternative. You don't have somebody come see them and go, okay, you get discharged. You go to inpatient, and here's this in-between place called EMPath. No, EMPath is the psych ER. It's where you move everybody. That's where the initial evaluation goes. That's where you determine whether or not somebody gets admitted or discharged. But usually you intervene and start treatment before you try to make that decision. The other difference is that we mentioned all those exclusions of the community programs before. EMPath should be as few exclusions as possible, hopefully no exclusions, other than people having a non-psychiatric medical emergency they should be able to take everybody just like everybody would go to labor and delivery unless they were hemorrhaging or having a heart attack. And once they get there, within the first 60 minutes of arrival, they should be evaluated by a psychiatrist. And then a treatment plan should be started where the staff are constantly working with somebody under constant observation and reevaluating, not trying to make a decision too quickly on what the ultimate destination is, but see how people respond to the treatment plan. Rejigger the treatment plan a bit, keep working with it to see if you can do something, helping people hopefully get them to that least restrictive level of care and constantly reevaluating to see if it's possible to avoid inpatient care. And you're doing this in a very calming, healing, comfortable setting, way distinct, way different than the medical ER with a wellness and recovery approach, which really helps people feel more comfortable. The space of these units is a large open room, which is so different than the ER, which is a bunch of individual small rooms, which can feel like cells or prison to psychiatric emergency patient. Instead, we have everybody together in this room, which feels like a big slumber party or a group camp out, high ceilings, ambient light. The floor is calming and soothing. It's designed where everybody gets a big recliner instead of being in a bed in an individual room. You've got a recliner in the big living room where you can go and you can hang out in your recliner. Once you choose it, it's yours, but you can get up and you can walk around. If you feel like pacing, which often helps our people having a psych emergency, then you can go ahead and pace. You don't have to beg anybody for something to drink or something to eat, which we found in psych units can often cause agitation or aggression because somebody doesn't have time to help them out or get them a glass of water. Here, you can get it for yourself. You can get yourself something to eat, drink. You can get yourself linens. Some places have areas you can go outside and they're actually designed so that you can go sit at a table and play a board game or have something amusing to do, read a magazine, read a book, do some coloring, or you can sit in your chair. You can fold it flat, grab yourself a blanket and pillow, take a nap. It's all about how do we help make you feel comfortable and engage and voluntarily work with us to help you get through this worst day of your life. It's actually, there are federal guidelines around these units now where there is an established design that there's 80 square feet overall per patient, but only 40 square feet around each chair. That other 40 square feet is that extra space where you can pace, you can do mindfulness, you can do exercises and yoga and things like that. You can have that table where you can go and sit and maybe play cards or dominoes or something like that or get yourself something to eat or drink. The other thing that's different is that the staff are intermingled. Instead of having that high security bulletproof fishbowl where the staff all kind of cower behind, staff are intermingled, they're intertwined. And what we find is that all the research shows open nursing stations actually have fewer assaults, fewer injuries, fewer episodes of agitation and aggression than the places that have those high security. As the difference is, if you're in a high security place, let's say, are you gonna feel the same way when you are in a maximum security prison or you're in the lobby of the Four Seasons Hotel? I don't think so. So when we make site facilities to be like high security units, people are on edge, people are nervous, people think their needs aren't getting met. They start deciding somewhere in the brainstem that they're gonna have to become agitated or aggressive to even get a glass of water. You have everybody intermingled, intertwined, and there's a big, big difference and everybody's calmer, you have much better outcomes. And even in these empath units, if you do have somebody who starts to become a little agitated, a little aggressive, starts to escalate, instead of calling security and putting them in restraints or in locked seclusion, we have voluntary calming rooms. Sometimes they're called comfort rooms where you can just escort them to and say, hey, we'll come in there with you. I can hang out with you for a bit. If you wanna be there by yourself, it's unlocked. You can come go as you please. It avoids 95% of restraining episodes. Here's what these units look like. These are in different units across the country. The one on the left is from Iowa. The one on the upper right is from Los Angeles. The lower right is from the University of Minnesota. Some of you may have seen in July of this year, the New Yorker did a huge feature article about empath units. This was the unit that they did as their core thing. The author, who's a physician himself, visited there. His name's Drew Coular. I'm gonna mention him in a moment. But it just shows you how different is that than what you imagine a typical medical emergency to be. And you can see that it's a much more comfortable and kind of self-reliant area to be inside. Here's some other ones from around the country. There's one where you can see where a patient is able to do some stretching and some mindfulness yoga-type exercises. And here's from who I just mentioned, the physician, Drew Coular, who was on staff at NYU Langone in New York City. And he actually flew out to see that empath unit at the University of Minnesota and made this incredible quote in that huge feature article he did about empath units in July, where he said, the empath unit's real innovation is a structural shift in how we think about space and time. He, as a physician, thought about usually considering drugs, devices, and procedures as what medical care was all about, but physical spaces can be therapeutic too. And that's such a great quote because it talks so much about what empath units are about, changing that physical environment and it changes people's perception in the way that they approach it. So we staff empath units with psychiatrists, with nurses, with social workers, with other psychiatric professionals and peer support specialists. I think most of you are familiar with folks with lived experience with mental illness who've gone through training and they're kind of like sponsors in AA. Somebody comes on the unit saying, hey, you're going through a crisis. I've been there too. Let's get you through this together. They've got the kind of one-to-one ability that nobody else can do and they're just fantastic. I suppose, so for the patients, the benefit is that you've got this wonderful trauma-informed unit, very home-like, very different from ED. It's very calming. They are not immediately obligated to go to inpatient, but we have a chance to work with them while they're feeling comfortable and avoid the hospitalization, which we're able to do 75 to 80% of the time. They see a psychiatrist right away and they're able to be restrained in these units. The usual numbers we see in empath units is that the restraints on this patient population who in a traditional ER, the same population would be in restraints 20 to 25% of the time. They're only being restrained one or two times out of every 1,000 patients. So one or two out of every 1,000 or 200 to 250 out of every 1,000. That's the difference. For the hospital, it's great. It's an EMTALA compliant place that you can quickly move people out of your ER to a better location for care and more immediate care for them, while at the same time opening up beds in your ER for the non-psychiatric emergency patients. So a lot of hospitals opened up empath units during the peak of the COVID crisis because they were looking at their ERs and saying, wow, half of our beds are taken up with psych patients boarding. What if we have a COVID surge? Where are we gonna put these people? And so by getting these psych patients to a better location for better care, that created capacity in the ER. It eliminated unnecessary admission, so it's good for the inpatient unit as well. No more denied payment admissions. Only people going there, people we've proven clearly need to be hospitalized and they arrive with a full day of documentation, psychiatric evaluation, and treatment on the chart. And you can actually cost-effectively do this because if you've got an unused space in your hospital somewhere, you can convert that into an empath unit because it just needs a big open room. There's no walls, there's not a lot of doors or anything, so it's very inexpensive to remodel and create an empath. So what we're trying to do is change an emergency patient into an outpatient, complementing that wonderful outpatient community crisis system. We're not replacing anything that's in the community. What we're doing is providing an emergency service that's better than we're already doing in the emergency department. So this is not intended to be something different or take away from what we're trying to do with community programs. It needs to be very clear. There's different levels of care. We want as many great community programs as possible for both pre and post the time that they're in the ER, but they shouldn't be in the ER. We can do better work in the empath unit. This is specifically for those high acuity patients who historically otherwise would have been stuck in an ER waiting for an inpatient bed. So real quickly, I've only got a couple of minutes left. I want to tell you about, now there are empath units being built all around North America, usually the United States and Canada. These are stars where they either already exist or are being developed and will be opening soon within the next year or so. You can see it went from the first of these being conceived in just the year 2015 to today. And we're talking about several dozen and it's just a wonderful how this idea has taken off and it's just flourishing around the country. And maybe some of you listening today might think, hey, let's do this at our site as well. And if so, you'll see my email at the end of the talk and I'd love to tell you more about it. It's always my time free to you because I just really believe in this. One of the most compelling arguments in favor of empath units is published in probably the most prestigious emergency medicine journal out there. It's called the Journal of Academic Emergency Medicine. They actually published this article a couple of years ago. It really came in the print article in February, 2022, when it was considered their highlight article. They did a podcast about this study. This was about the empath unit at the University of Iowa. I showed you a picture of it before. Here's the things that they were able to demonstrate with that empath unit six months before it opened compared to six months after it opened. Here was some of the differences in that. They reduced the emergency department length of stay from over 16 hours for all psych patients to under five hours. And that was for the entire time when they were there, not just the medical avail, but if they came in for an overdose or other medical problems, so they had to have time in the ER, they still reduced that by just an incredible amount, 70% reduction. Those patients who came to the ER with a psych emergency, they reduced the number of them needing to go to the inpatient unit by 53%. Those might make sense from everything I already talked about, but here's some great things they found in their study that it was even more mind blowing. The chances of people going to their first outpatient mental health appointment after staying in the empath unit was 60% better than people being discharged from inpatient. That's amazing. That means maybe we're changing those cycles. And a lot of those people who came in before and would not go to that inpatient follow-up appointment, suddenly they're going. Maybe we're teaching people that we're not their enemy, that we're their advocates, we're their allies, we're working together with them. And maybe instead of them throwing out their meds and their recommendations as they walk out the door from inpatient, they're like, hey, those people really seem to care about me. Maybe I should take my meds, maybe I'll follow up. And then we've changed that emergency patient into an outpatient. And what's the result of that? We're seeing that the 30-day return to the emergency department, the recidivism, was decreased by 25%. And we've seen it as many as 50% in other places around the country, which is really amazing because so many people talk about, oh, well, you're just seeing the empath for 24 hours. We're used to them having a five-day admission. You just haven't treated them long enough. They're just going to come right back to the ER. Well, au contraire, they're actually not coming back because we've changed that cycle and they're coming back fewer and fewer because maybe we've changed that emergency patient into an outpatient. But here's even an argument you can make to your hospital who might say, we don't have the money for this. This study showed that in that first year alone, they actually added $861,000 to the emergency department's bottom line by moving those behavioral health patients out of the ED to a better location for care. And by doing so, dramatically reduced sitter hours, security costs, the left without being seen patients, all these other things. We're getting people better care and saving tons of money at the same time all across the board. Isn't that a wonderful thing? We're even reducing the lengths of stay for those people who do get admitted. There's one at the University of Minnesota. They're now only admitting 83, they're only admitting 17% of patients that they see in their empath unit from their ER. 83% of the folks they see go home in a matter of hours. You say like, oh, well, this is just for big academic centers or maybe for urban centers. No, it's designed to be something you can do at academic centers, at community hospitals, big urban settings, really remote rural settings. The Billings Clinic in Montana, pretty remote. They see patients coming from a hundred miles in every direction. In 2017, they opened up an empath unit for adults and for adolescents and child. Same kind of numbers we're talking about. Reduction in the ER length of stay, readmissions drop way down, recidivism to ED drop right down, almost zero use of seclusion restraint and saving millions of dollars each year. In Los Angeles, the absolute opposite of Montana, we see the same kind of numbers coming where 81% of the patients we see get discharged home. Average length of stay, we haven't talked about that. Usually want people to have a long enough time that the treatment and the evaluation is not something we decide too quickly. 16 hours, that's a nice average length of stay because once you've decided after about 10 to 12 hours what the disposition should be, you have a few more hours to work on getting people out. You still have an average length of stay well under 24 hours. They're one of the ones we work with people a lot, the California government saw is the one in Sacramento, California. They had a stack up area in their emergency department. They call their hall of shame where they just had those journeys. Sometimes they'd have 10, 12 patients just stacked up on top of each other waiting for an inpatient transfer. Before this unit opened in 2019, the average length of stay in their ER for a psych patient was 33 hours. They opened up the empath unit. After the first month, it was 19 hours. Two months later, it was seven hours. Now their average length of stay overall with all the medical things they do, three hours. Once they call the empath unit, they move them out in less than an hour and 80% of the folks get discharged home. Here's something else we didn't talk about, patient satisfaction. They actually, the patients, 85% of them said they had a great experience in the empath unit. Think of this. The vast majority of these patients came in involuntarily. Their day started in the back of a police squad car for the crime of being suicidal. And by the end of their day, they had a good experience and said positive things. What a remarkable turnaround that is. And the recidivism again here went way, way down. The National Council for Behavioral Health identified in their really wonderful publication, The Roadmap to the Ideal Crisis System, where they are talking about all those crisis programs and all the different things you can do outside of the hospital, which are wonderful. You still need an empath unit. There should be one in every mental health system. Real quick, it's just I'm finishing up here. If you need to make a financial argument, if you wanna do this, if you're holding people and let's say we're talking about Medicaid, you're holding people to send to an inpatient psychiatric hospital, that average inpatient stay costs $12,000. The average empath unit stay under Medicaid is reimbursed at $2,000. We're averaging across the country. We see this number over and over. It's always between 70 and 80% of the people who's historically would have gone to inpatient facilities were able to stabilize, get better and send them back home in less than 24 hours. So if we're able to do that for $2,000 and avoid inpatient stay for three out of every four patient, that means just for every four patients we see, we're saving Medicaid $36,000 for just a cost of 8,000. How is that not a win-win? That's documentable savings. And so it means that we're making a better use of the money and it's a win for Medicaid, but most of all, it's a win for patients who are getting the help they needed much faster than they did in the past. The Sacramento unit that I showed you a second ago, in their first two and a half years of being open, they did an internal study and they were able to show they saved their area of Medicaid $45 million while providing much more better, timely care and stabilization. Based on some of these things, the state of California in the last year gave out 11 grants of $3 million each for hospitals to build empath units by name. And then following that, South Carolina heard about it and said, that's a great idea. We're gonna give out 13 grants to hospitals totaling $45 million so that they can build empath units. And hopefully we're gonna see this in states across the country. It's a common sense solution. It makes so much sense. And we hope that this happens more across everywhere. And I hope that you found this interesting and illuminating and we'll be happy to take any questions. Sorry, I wanted probably a bit longer than I'd hoped to. Thank you, Dr. Zeller and don't ever apologize. I think people on the call understand why I was so excited about you doing this presentation. It's a phenomenal model and can be game changing. I'm gonna try to, cause we do just have a couple of minutes, but two of the questions are kind of connected. One is what does the non-medical intervention look like on the unit? Is it a psychosocial assessment? Is it therapy? And then connected to that, what about privacy? If everybody's in one big room, what about people who need privacy? And then I'm gonna go ahead and give you the third one too, which is what about pediatrics? Has this been, is this relevant for people under 18? Yes, okay. So those are, they're all great questions. So those are ones that come up a lot. First off, the assessment is, usually the first assessment is as quickly as possible, getting to a psychiatrist or psychiatric provider. And a lot of our research was, there's a lot of people having psychiatric emergencies would go to traditional psychiatric emergency or crisis settings. And after several hours go, I've been here five hours, I haven't even talked to the doctor yet. And so what we wanted to do is get the doctor closer to the front of the line. Everybody else's assessment, social worker, nursing, all that is super, super important. We wanna have that. But we want to get the doctor as close to the front of the line as possible because if meds are indicated, if medical interventions are indicated, we wanna make sure those get started right away and help to start relieving people's suffering. When we're talking about privacy, yes, we have a big room where everybody's in together, but for the interview and the actual assessments, they're going into a closed room with that provider, with the social worker, with the therapist to do those assessments and interventions. But then the rest of the time they're out with that group camp out. And it might be a little different than what some of us might think we would want in that situation, but here's something really neat. That first few hours of crisis, human contact is so important and it's such a changer for you in that you don't wanna be all alone. You don't wanna feel isolated. Things are really awful because you feel like you're separate. If you're suddenly in a space where there's plenty of other folks who maybe understand what's going on and can engage with you. Let me look at it real quickly. Let's say that you're super suicidal and you go to the hospital and you don't wanna take another breath on earth. You wanna die and they put you into your own room in a psychiatric facility and they close the door behind you and you lie down on the bed. You look up at the ceiling and what's changed? As far as you know, that everybody in the world still hates you. It's a horrible place. Why should I keep living? You go in to instead that first few hours, you're in an empath unit and there's other people there. And maybe you talk to a staff member or a peer support specialist or maybe even another patient and you start to suddenly you made a new friend. Maybe the world's not such a bad place. And maybe you've got some optimism and then we can work together on that and get it so that you are gonna keep living and have a better life. And that's the difference in those first few hours of crisis of being around other people and feeling like you're not alone with this. You're not the only one in the world having a tough time. And there's other people who are just like you who are going through this and everybody's gonna get you through this together. That's how it's a win. Wonderful. And NAMI's mantra is you are not alone. So that's a perfect example for it. Just super quickly, has this ever been tried with people under 18? Oh yes, yes, yes. And sorry, you did ask me that. That's okay. Yeah, there are, like I showed with the Montana one, that actually had a separate pediatric adolescent unit. The biggest growth on empath right now is for the pediatric population. Both the California and South Carolina grants has specific set asides for the pediatric empath group. The neat thing about it is that it may be a little different. There may be more access to families. Kids are more complicated with the whole kind of who's in charge and the issues. And we need to get a lot of people together. The empath units then are built with a family meeting room adjacent to the unit. But you can still get a lot of benefits out of that space. And kids like being with each other too, just like adults do. So it works great. And the key thing about it is once again, instead of feeling like you're in this isolation, there's something wrong with you, there's nothing interesting in front of you instead of a wall, being somewhere where you feel comfortable, you feel like you're in a clubhouse, there's a lot of reason to feel positive. And then that helps you to relax and allow the treatment to work and allow things to get better and start feeling optimistic. And when those things happen, the chances of you having a better outcome go way, way, way up. And that's what it's all about. Absolutely. Thank you so much, Dr. Zeller. And if you will go to the next slide, please. I wanna take just a minute to let you know that SMI Advisor is accessible from your mobile device. You can use the SMI Advisor app to access resources, education, upcoming events, complete mental health rating scales, even submit questions directly to the team of SMI experts. So you can download the app now. And if you'll go to the next slide, please. And let's go over, cause we've already, yeah, let's go. There we go. If there are any topics covered in the webinar, there ought to be, that's the bibliography. Can we go one more? There we go. There are any topics covered in the webinar that you'd like to discuss with colleagues? One question that came up that we didn't have time to get to was what about rural areas where there aren't psychiatrists available? So I can see that being a question that person- Can I just add real, real quick? There's a number of rural areas that are doing collaboratives where there's several hospitals and maybe there was one rural critical access hospital that was about to close and they're making that into an empath unit and they're using telepsychiatry to staff it so that all of the region's patients can go to there or be transferred to there so that they've got a place to go. They're working on that now in Northern Tennessee and that's kind of what they're doing in Montana as well. So it can be done in rural areas. So I just want to make sure people heard that. But anyway- Where there's a will, there's a way. Where there's a will, there's a way. Thank you. Exactly. But the SMI Advisor, through our consults, this is an easy way to network and share ideas with other clinicians who are participating in this webinar. If you have questions about the webinar or any topic related to evidence-based care for serious mental illness, you can get an answer within one business day from one of the SMI Advisor's national experts. This service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with people who have serious mental illness. Completely free and confidential. Next slide, please. These are some additional resources. We offer more evidence-based guidance on emergency care, such as My Mental Health Crisis Plan. This app allows individuals to create a plan to guide their care in case of a mental health crisis in only a few minutes. And you can download the app by clicking on the link in the chat or by downloading the slides. To claim your credit, if you'll go one more slide, Dr. Zeller, to claim your credit for today's webinar, you need to meet the requisite attendance threshold for your profession. After the webinar ends, please click continue to complete the program evaluation. And the system then verifies your attendance to claim the credit. This may take up to an hour and can vary based on local, regional, and national web traffic. Next slide. Please join us on November 16th as Dr. Carol Warshaw presents Gender-Based Violence in Mental Health, Key Considerations for Clinical Practice. Again, this is a free webinar, November 16th from three to four Eastern. And thank you again for joining us. And Dr. Zeller, thank you. We had very few people who dropped off the call even though we ran over. And I think that shows you the interest in this topic. So thank you for joining us.

EMPath units

emergency psychiatric care

psychiatric emergencies

Zeller's six goals

safe environment

discharge planning

hospitalization rates

multidisciplinary team

outpatient care

community-based crisis services