Bibliography - Care Delivery

Resources Related to Improving Treatment of Behavioral Health Patients in Emergency Department Settings
* Resources that are not specific to behavioral health are preceded by an asterisk.

Agency for Healthcare Research and Quality. Service Delivery Innovation Profile: Coordinated, intensive medical, social, and behavioral health services improve outcomes and reduce utilization for frequent emergency department users. (10/23/2013)
Available at:

  • This profile describes an initiative in Grand Rapids, Michigan. Intensive, concurrent medical and behavioral health care, addiction services, and social service coordination improved patient outcomes and reduced health system use among patients who had been frequent users of emergency departments.

Rosenberg L, Ingoglia C. Lost in Transition: Addressing Continuity of Care (PowerPoint from a webinar)
NASMHPD Fifth National Summit of State Psychiatric Hospital Superintendents (May 7, 2007)
National Council for Community Behavioral Healthcare, Rockville, Maryland
Available at:

  • Hospitals and community-based organizations need to ensure that patients with serious mental illnesses who fail to show up for treatment after hospital discharge are not forgotten. Seeking to reduce the number of patients who are "lost in transition," the National Council for Community Behavioral Healthcare assembled a panel of experts to develop an approach to coordination between inpatient and outpatient settings and to engage people with mental illness in continued care. The panel included representatives from leading accrediting bodies and hospital and community treatment organizations as well as patients, family members, researchers, state authorities, and psychiatric leaders.

American College of Emergency Physicians. ACEP Psychiatric and Substance Abuse Survey 2008.
Available at:

  • Responses to a 2008 ACEP survey of emergency department medical directors indicate that the increasing use of the ED for psychiatric care along with the lack of available resources has a negative effect on all patient care in the ED.

* American College of Emergency Physicians. ACEP Task Force Report on Boarding: Emergency Department Crowding, High Impact Solutions (2008). Accessed December 10, 2013. Available at:

Bender D, Pande N, Ludwig M. A Literature Review: Psychiatric Boarding. The Lewin Group
Contract #HHS-100-03-0027; Department of Health and Human Services; October 2008
Available at:

  • From the Conclusion: “To date, no comprehensive, nationwide academic evaluation of psychiatric boarding detailing the extent of the problem exists. Much of the information on the prevalence of psychiatric boarding comes from individual hospital analyses, association surveys or anecdotal media publications….Limited data on this topic is suggestive of a widespread problem causing serious disruption of the service delivery system in a substantial number of communities. However, geographic variation, lack of robust evaluations and data indicate that further academic studies on this topic are needed.”

Coffey RM, Houchens R, Chu BC, Barrett M, Owens P, Stocks C, Vandivort-Warren R, Buck J. Emergency Department Use for Mental and Substance Use Disorders. Online August 23, 2010, U.S. Agency for Healthcare Research and Quality (AHRQ). Available at:

  • This study used administrative data to compare the use of community hospital EDs by adults with mental and/or substance use (M/SU) disorders and by adults with other chronic diseases. Patients with more severe M/SU disorders were more likely to have multiple ED visits in a year. Patients with Co-Occurring M/SUD were most likely to use ED services repeatedly and at almost twice the rate of patients with Mental Disorders Only, Substance Use Disorders Only, diabetes, or chronic respiratory disease. While it is not known what the level of ED utilization should be for a particular chronic disease, higher utilization by patients with Co-Occurring M/SUD raises two issues: 1) it suggests that M/SU disorders are chronic conditions that need to be well managed to reduce costly, repeated use of emergency services; and 2) it raises questions about access to outpatient care and to effective preventive services for people with M/SU disorders.

* DeLia D, Cantor J. Emergency department utilization and capacity: Research Synthesis Report No. 17. Robert Wood Johnson Foundation; July 2009. Available at:

  • ED overcrowding is most often caused by the inability to move admitted patients from the ED to an inpatient bed. This bottleneck may be caused by inefficiencies in the way patients flow through various hospital units or shortages of key resources (e.g., staffed beds) in the local service area, particularly during periods of peak demand. Limitations in hospital staff, particularly specialists willing to work on-call in the ED, also contribute to ED overcrowding.

Manton A. Psychiatric Patients in the Emergency Department: The Dilemma of Extended Lengths of Stay.
Emergency Nurses Association, March 2010. Available at:

* National Quality Forum. Regionalized Emergency Medical Care Services: Emergency Department Crowding and Boarding, Healthcare System Preparedness and Surge Capacity—Performance Measurement Gap Analysis and Topic Prioritization. (Final Report) December 31, 2012. Available at:,_Healthcare_System_Preparedness_and_Surge_Capacity.aspx

  • While there are proven interventions to reduce ED and hospital crowding and boarding, many hospitals do not have a strategy to address the crowding issue locally. This report discusses issues to consider in the development of standards for hospitals, healthcare systems and regions in the areas of ED and hospital crowding including boarding and diversion, emergency preparedness, and surge capacity.

Phillips L. Performance Improvement: Improving Processes to Reduce LOS for Behavioral Health Patients in the ED.
St. Anthony Hospital, Oklahoma City 4/2010. Available at:

  • Without adding new staff or new costs, St. Anthony Hospital in Oklahoma City - as part of the Institute for Behavioral Healthcare Improvement (IBHI)'s Collaborative on Improving Care for Behavioral Health Clients in Emergency Departments - changed internal processes and reduced the amount of time mentally ill patients spend in its ED in a crisis situation, cut in half the time these patients wait before they can get to a bed, and decreased the time these patients must wait in the ED before they can meet with a mental health professional.

* Agency for Health Care Research and Quality (2012). Emergency Severity Index, Version 4: Implementation Handbook, 2012 Edition. Available at:

  • The ESI is a simple to use, five-level triage instrument that categorizes ED patients by evaluating both patient acuity and resources.

Agency for Health Care Research and Quality (5/22/2013). Service Delivery Innovation Profile: Streamlined evaluation, transfer, and admission processes significantly reduce waiting times for emergency department patients awaiting admission to psychiatric facility. Available at:

  • A multidisciplinary team from a medical center and its affiliated psychiatric hospital streamlined the evaluation, transfer, and admission processes for psychiatric patients presenting to the emergency department, leading to a significant decline in waiting times before transfer to the psychiatric facility.
  • See the related article: Improvement report: reducing length of stay in the emergency department for psychiatric patients. Institute for Healthcare Improvement. Available at:

American Psychiatric Association, Work Group on Psychiatric Evaluation (2nd Ed). Psychiatric Evaluation of Adults. APA, 2006
Available at

Betz, M. E., Miller, M., Barber, C., Beaty, B., Miller, I., Camargo,, C. A. and Boudreaux, E. D. (2016), Lethal means access and assessment among suicidal emergency department patients. Depress. Anxiety. doi: 10.1002/da.22486

  • Among these ED patients with SI/SA, many did not have documented assessment of home access to lethal means, including patients who were discharged home and had ≥1 firearm at home.

Coristine RW, Hartford K, Vingilis E, White D. Mental health triage in the ER: a qualitative study.
Journal of Evaluation in Clinical Practice 2007; 13: 303–309. Available at:

  • A defined triage process coupled with the use of psychiatric nursing staff may be applicable to ERs within general hospital settings to improve ER functioning, focus support for persons with mental illness and further integrate ERs within the community mental health model. At-Risk for Emergency Room Personnel: Screen ED Patients for Substance Abuse and Suicide Risk. Available at:

  • At-Risk for Emergency Room Personnel is an online, 1-hour interactive gatekeeper training simulation that uses virtual role-play to help Emergency Department medical and support staff identify patients at-risk for suicidal ideation and substance abuse. The training covers several evidence-based screening tools.  *At-Risk in Primary Care: Identify & Manage Treatment of Patients with PTSD, Depression, Substance Abuse, & GAD. Available at:

  • At-Risk in Primary Care is a CME and CNE approved online training simulation designed to help prepare primary care providers to recognize when a patient’s physical ailments may be masking underlying trauma-related mental health disorders such as PTSD or depression and how to build a treatment plan.

National Institute of Clinical Studies. Victorian Emergency Department Mental Health Triage Project 2005–2006: Training Manual. Victorian Government Department of Human Services, Melbourne, Victoria, Australia; 2007.

Tintinalli JE, Peacock FW 4th, Wright MA. Emergency medical evaluation of psychiatric patients. Annals of Emergency Medicine 1994 Apr; 23(4): 859-62. Available at:

Dawes SS, Bloniarz PA, Mumpower JL, Shern D, Way BB. Supporting Psychiatric Assessments in Emergency Rooms.
Albany, NY, Center for Technology in Government, 1995.
Available at:

  • “An inappropriate decision to admit or discharge a psychiatric patient from an emergency room is often the starting point for a series of undesirable results.”
  • With the assistance of an expert panel representing both practitioners and consumers of mental health services, the Center for Technology in Government at SUNY-Albany developed a computer-assisted decision model to support psychiatric assessments in emergency rooms.

Vingilis E, Hartford K, Diaz K, et al. Process and outcome evaluation of an emergency department intervention for persons with mental health concerns using a population health approach. Administration and Policy in Mental Health 2007; 34: 160 –71.
Available at:

  • This report on an evaluation of an emergency department’s use of a mental health triage process and crisis counsellor for persons presenting with mental health concerns finds that the intervention led to significant reductions in wait time, security incidents and hospital admissions; increased follow ups with a community agency, medications and a psychiatrist; and decreased follow ups with detox.

Wynaden D, Chapman R, McGowan S, McDonough S, Finn M, Hood S. Emergency department mental health triage consultancy service: a qualitative evaluation. Accident and Emergency Nursing 2003; 11: 158–65.
Available at:

  • An evaluation of staff perception of a three-month clinical trial of an emergency mental health triage and consultancy service finds that ED staff believed the service made a valuable contribution to the overall functioning of the ED.

Bluebird G. “Paving New Ground: Peers Working in In-Patient Settings.” Supported by the National Technical Assistance Center, National Association of State Mental Health Program Directors; Alexandria, VA: 2008.
Available at:
(Note – this is not specific to the emergency department.)

  • This “lessons learned” guidebook details the development of peer roles in mental health settings, and identifies and highlights some of the hospitals in the country that have been most successful.

Ostrow L. (Spring 2010) “A Case Study of the Peer-Run Crisis Respite Organizing Process in Massachusetts.” Heller School for Social Policy and Management. Available at:

  • Peer-run crisis respites (PRCR) are alternatives to traditional psychiatric crisis care, operated by trained mental health consumers (i.e. peers). They provide an alternative to emergency and inpatient services that are customarily utilized by this population. This brief is a case study of the peer-run crisis respite (PRCR) organizing process by a group of consumers in Massachusetts, with recommendations for other states and counties who wish to design, lobby for, and implement PRCRs.

Ostrow L, Dan Fisher D. (2011) “Peer-Run Crisis Respites: A review of the model and opportunities for future developments in research and innovation.” Available at:

  • This paper describes what a peer-run crisis respite (PRCR) is and the operations of existing PRCRs, and reviews some of the evidence of effectiveness and cost of PRCRs.

People, Inc. (2011). Hospital Diversion Services: A Manual on Assisting in the Development of a Respite/Diversion Service in Your Area. Available at:

  • This manual on how to open a Peer-Operated Hospital Diversion service is intended to assist peer-operated providers with the operational functions of the service.

National Empowerment Center: Crisis Alternatives  Accessed December 12, 2013

  • This web page provides a variety of resources related to peer-run crisis alternatives.

Fisher D, Levin C. Peer-Run Crisis Respite Centers (video)
Available at:

  • Two peer advocates describe the process they underwent to get peer-run crisis respite centers supported in Massachusetts, providing a detailed and practical discussion about issues such as building community among stakeholders and how to present proposals to politicians.

Substance Abuse and Mental Health Services Administration. “What are Peer Recovery Support Services?”
HHS Publication No. (SMA) 09-4454; 2009. Available at:

  • This paper provides an overview of peer recovery support services.

SAMHSA – HRSA Center for Integrated Health Solutions: March 30, 2011
“Peer Support Wellness Respite Centers.” Available at:,%20PSWRC.pdf

  • This document is based on a webinar presented by a group of peer leaders who provide an overview of the peer respite model, core components, research and practical experiences from peer providers operating programs in two states (New York and Georgia).

North Carolina Department of Health and Human Services
Press Release: August 16, 2013
Go to:

Governor McCrory Announces Statewide Telepsychiatry Plan to Improve Quality and Access to Mental Health Care

  • From the press release: The statewide telepsychiatry program begins operations in January 2014. It will link hospital emergency departments to mental health professionals who can initiate treatment for emergency department patients in mental health or substance abuse crisis. By using secure, real-time interactive audio and video technology, telepsychiatry will enable a mental health provider to diagnose and treat individuals needing care at any remote referring site. The state will invest $4 million over two years in the statewide telepsychiatry program and it will be overseen by the DHHS Office of Rural Health and Community Care.
  • Fact Sheet: Using Technology to Take on NC’s Toughest Mental Health Challenges
    Available at:
  • Statewide Telepsychiatry Plan available at:

Silver Award: Statewide Telepsychiatry Initiative, South Carolina Department of Mental Health and University of South Carolina School of Medicine, Columbia—A Collaborative Partnership Brings Telepsychiatry to South Carolina Emergency Departments. Psychiatric Services, November 2011; 52(11): 1390–1391. Available at

For more on this program, see the following.
South Carolina Department of Mental Health
DMH Telepsychiatry Program
Go to:

  • Summary: DMH and the South Carolina Hospital Association (SCHA) requested assistance from The Duke Endowment (TDE) to develop a statewide telepsychiatry network for all SC hospitals operating emergency departments (EDs) and received the first grant on November 30, 2007. To date, the program has received more than $7.25 million to this end. The continuing objective of the program is to make psychiatric consultation available in all SC EDs at any hour. The consultations have increased the quality and timeliness of triage, assessment and initial treatment of patients; reduced the number of individuals and length of stay in EDs; and allowed hospitals to direct critical personnel and financial resources to other needs; thus, realizing financial savings for hospitals.

AHRQ Health Care Innovations Exchange (12/4/2013)
Service Delivery Profile: Statewide Partnership Provides Mental Health Assessments via Telemedicine to Patients in Rural Emergency Departments, Reducing Wait Times, Hospitalizations, and Costs.
Available at:

  • Through a statewide telemedicine program, psychiatrists evaluate patients with mental health issues who present at rural hospital emergency departments, leading to reductions in wait times, inpatient admissions, and costs; increased attendance at followup visits; and high levels of patient and clinician satisfaction.

Last updated January 2014

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