Avoiding The ER: Paramedics Link Patients To Local Mental Health Treatment

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For Kelly Kjelstrom, plugging the gaps in mental health care can mean something as simple as a late-night taco and a friendly chat with a patient.

Kjelstrom, 45, is a community paramedic in Modesto, California. Part of his job is to help psychiatric patients avoid the emergency room, where they can get “boarded” for days, until they are released or a bed opens up at an inpatient facility.

When a 911 call involves a potential mental health crisis, specially trained paramedics like Kjelstrom are dispatched to identify problems, de-escalate the situation and intervene.

After doing a physical assessment, they talk to the patient to figure out what the issue is, also asking about a patient’s mental health history, drug use and insurance status. They use that information and their knowledge of resources available to plan the next steps for the patient — maybe it’s a hospital or a psych facility, maybe it’s outpatient care.

Increasingly, these paramedics also become involved in follow-up care. Kjelstrom estimates that he spends twice as long on patient visits as he used to. He builds relationships with people. While out on duty, if he sees a familiar face, he stops and checks in, sometimes over a night-time snack.

“One of the patients we see on a regular basis,” Kjelstrom said. “I buy him a taco, no big deal, and I remind him to take his meds.”

That simple interaction, he said, can keep someone out of the ER and on the path to better health.

The Modesto pilot program launched a year ago, as one of 13 “Community Paramedicine” pilot projects in the state led by the California Emergency Medical Services Authority. It is the only such project in California to focus on mental health. The other 12 address such issues as reducing the number of frequent 911 callers and reducing patient readmissions after hospital stays.

Paramedic mental health projects like Modesto’s are underway in North Carolina, Minnesota, Texas, Colorado and Georgia. Other states, such as Washington and Nevada, have shown interest.

“Emergency departments are bursting at the seams,” said Kevin Mackey, medical director of the Mountain Valley EMS agency, who launched the Modesto initiative. “This is at least a partial answer to giving people care in the right place at the right time.”

Mental illness, which affects about 1 in 4 adults, has become  a national concern. Cases like October’s police shooting of a woman with schizophrenia in New York have sparked conversation about ways to better reach these patients.

“If we could coordinate care — if we have the right medications and the right coordinating approach to these patients, we can avoid shooting people,” Mackey added.

Lou Meyer, who oversees the community paramedic projects for the California emergency authority, said that since the Modesto program started, more people are going straight to clinics or using other mental health resources, rather than sitting for hours in the ER waiting for help.

UCSF researchers are evaluating how well the community paramedic pilots are working, and Meyer said they’ll report their findings early next year.

The efforts in this state are funded by the California Health Care Foundation through November 2017. (California Healthline is an editorially independent service of the California Health Care Foundation).

Meyer explained that hospitals and other providers could sponsor legislation to fund these projects for the longer term.

Other states are beginning to see the benefits, too.

In Wake County, North Carolina, for instance, a third of mental health-related 911 cases are now sent to specialized psychiatric facilities, said Michael Bachman, deputy director at the county’s Office of Medical Affairs. That’s about 350 patients a year who would otherwise have gone to ERs.

Kjelstrom, the Modesto paramedic, says he sees patients who would benefit most from a short stay in a dedicated mental health facility. But often he finds that the local centers don’t have enough beds for those who need them. That limits how effective he can be, he said.

The thing that has to improve is there has to be more access to places for patients to go.

Michael Bachman

Mackey, of Mountain Valley EMS, estimates that 30 percent of the time, no bed is available for a patient who needs one.

Follow up care is hard to come by, as well.

“If we’re talking about using community paramedics — or social workers, or some other community organization — to connect people with behavioral health care services, [these kinds of barriers] are an issue,” said Kate Blackman, a senior policy specialist for the health program at the National Council of State Legislatures.

Even so, experts say, community paramedic programs are a promising first step.

“We’re moving in the right direction with programs like these,” said Karen Shore, a principal at the California-based consulting firm Transform Health. “It isn’t solving all of our health system problems. But that’s not a fair expectation.”

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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