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Closing the health gap: the development of a mobile psychiatric treatment team

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Closing the health gap: the development of a mobile psychiatric treatment team

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Content Running head: CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 1
Closing the Health Gap: The Development of a Mobile Psychiatric Treatment Team
Lisa Krekler, MSW, LCSW
University of Southern California
Dr. Manderscheid
May 2019
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 2
Closing the Health Gap: The Development of a Mobile Psychiatric Treatment Team
Executive Summary
The proposed one-year pilot innovation addresses the Grand Challenge of Social Work to
Close the Health Gap (Spencer et. al., 2018) brings a mobile interdisciplinary team of providers
to patients in the emergency room (ER). A psychiatrist will be available virtually 24 hours a day,
and an onsite Psychiatric Registered Nurse (PRN), Social Worker (SW), and Mental Health
Worker (MHW) will provide immediate crisis intervention to people in a mental health crisis
seeking help in the ER. The Mobile Psychiatric Treatment Team (MPTT) will evaluate, treat,
and provide a safe environment and case management after discharge for up to 30 days to
decrease readmission to the ER. The MPTT will have 23 hours and 59 minutes to stabilize the
acute crisis or transfer the patient to an inpatient hospital, ensuring treatment at the least
restrictive level of care. The MPTT plans to collaborate with hospitals to develop a designated
space away from the ER to allow patients the specialized care in a calm and therapeutic
environment. The MPTT is the only mobile team with a virtual psychiatrist and offers short-term
case management ensuring continuity of care to bridge the gap until a patient establishes
outpatient connections.
Patients seeking behavioral health treatment in crises are left with few options. Calling
911 or going to the nearest ER are the most immediate ways to seek emergency care due to lack
of available outpatient and inpatient mental health treatment. ERs have become the safety net in
the community, and they are not equipped to treat this vulnerable population. Individuals who
may be a danger to themselves or others, or who are unable to care for themselves, are being
detained in the ER while awaiting transfer to an alternate location for specialized treatment.
While ER boarding has become a common practice, it has been identified as a problem across
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 3
the nation without a resolution. Boarding has been defined by the American College of
Emergency Physicians (ACEP; 2018) “as a patient who remains in the emergency department
after the patient has been admitted or placed into observation status at the facility but has not
been transferred to an inpatient or observation unit” (para 2). Patients are often held for hours to
days awaiting the possibility of an inpatient psychiatric bed to become available. When a bed
does not become available, patients are discharged home without ever receiving psychiatric
intervention. Boarding is problematic not only for the patient but also for the staff, hospital, and
the community the hospital serves. When the decision has been made to transfer the patient to an
alternate level of care, and the patient remains in the ER, this prevents other patients from being
admitted into the ER. Many ERs must divert ambulances due to being at capacity and the length
of wait times for patients to be seen increases leaving hospitals unable to respond to emergencies
in the community (ACEP, 2018). Alternative interventions are needed now to address this issue,
and the solution is to integrate mental health into the traditional medical hospital setting at the
source of the problem.
A serious problem related to ER boarding is that suicidal patients are being held in the
ER without mental health treatment for more than 24 hours. It is hypothesized that if patients
with mental health conditions are treated immediately, there will be a higher rate of discharge to
lower levels of care, which will eliminate ER boarding, decrease transfers to inpatient beds, save
money, and decrease disparity and stigma attached to mental health, with the ultimate goal to
close the gap in health care. The proposed innovation addressing the Grand Challenges of Social
Work (GCSW) to Close the Health Gap is the development of the MPTT (Spencer et. al., 2018).
The competitive advantage is bringing the inpatient behavioral health team to the patients in the
ER, rather than transferring the patient to the hospital for acute mental health care. The purpose
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 4
of the innovation is to integrate behavioral health into a general hospital setting to close the gap
in services. The MPTT consists of a traditional inpatient treatment team, including a psychiatrist
and a psychiatry resident who will be available virtually 24 hours a day. The onsite staff includes
a PRN, SW, and MHW who are mobile and able travel to the patient to provide mental health
treatment. The team would care for the patients after being medically cleared in the ER and
transferred to a separate unit within the hospital site, but away from the ER. The team would
immediately begin to treat the patient utilizing interventions to address the specific crisis in the
least restrictive level of care within 24 hours.
The mission of the MPTT is to bring mental health treatment directly to the patient,
ensuring dignity and respect in a nonstigmatizing setting while providing the least restrictive
level of care. The MPTT concept is innovative because of the mobility of the entire team in a
nontraditional medical environment and utilizing a virtual psychiatrist around the clock. Since
ER boarding is a problem for ERs across the nation, this innovation can be implemented beyond
the pilot in San Diego, CA; however, the intent is to scale the program to other settings
throughout the United States to establish interventions available at any point of entry for this
vulnerable population.
The specific aims of the proposed pilot of the MPTT are the development of a specialized
unit within the hospital setting outside of the ER where the team will provide crisis intervention
and manage their safety for up to 24 hours. The MPTT expects to treat 1,825 people in one
hospital in the first year of the pilot program. Each patient will be discharged to the appropriate
levels of care, which includes continued case management for up to 30 days post discharge to
encourage engagement of community resources and decrease recidivism of returning to the ER.
The pilot also aims to reduce the stigma of help-seeking behaviors, allowing patients to receive
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 5
mental health treatment at the point of entry. Clinical self-report measures will be used to
evaluate the success of this pilot, length of stay, and rates of discharge to lower levels of care
versus inpatient hospital transfers. The outcome of this intervention will decrease ER boarding of
patients with mental health conditions and de-escalate the crisis while reducing the need for
inpatient psychiatric hospitalization transfer, ultimately improving access to care while providing
cost savings to hospitals, insurance companies, and patients.
The MPTT represents an innovative step forward in changing the trajectory of care not
only in the ER but also in the community. After the one-year pilot is complete, the vision is to
partner with the County of San Diego to develop a stand-alone Psychiatric Emergency Services
(PES) program open 24 hours a day to have mental health treatment available on a walk-in basis
to everyone in the community. Patients will benefit from improved access to mental health
services through the expansion of MPTT services and implementation of mental health treatment
to patients in the ER.
Conceptual Framework
The consequences of ER boarding result in suicidal patients being held in the ER
untreated for more than 24 hours while awaiting transfer to an inpatient psychiatric bed.
Boarding in the ER occurs across the nation due to inadequate resources for patients with mental
health symptoms (Alakeson, Pande, & Ludwig, 2010). Specifically, a lack of funding, outpatient
treatment options, and dwindling beds for acute inpatient psychiatric care prevent patients with
mental health conditions from accessing appropriate care and impacts ER overcrowding (Nesper,
Morris, Scher, & Holmes, 2016; Nolan, Fee, Cooper, Rankin, & Blegen, 2015). Without viable
treatment options, patients are left calling 911 or going to the nearest ER when in crisis; although
these options may offer immediate safety nets, they do not provide mental health treatment
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 6
(Hepburn, 2017; Montgomery, Metraux, & Culhane, 2013). The ongoing problem within the
mental health system has contributed to patients in a psychiatric crisis being held in the ER
without mental health treatment for more than 24 hours. The GCSW to Close the Health Gap
developed by the American Association of Social Work and Social Welfare (AASWSW)
highlights the need for improved access to services and improving equity in health care and
innovative solutions to bridge the gap in services (Spencer et al., 2018).
The problem of ER boarding is socially significant because there is a disparity that exists
between medical and mental health admissions to the ER, including increased length of stay, ER
staff who are not trained to treat behavioral health crises, and lack of treatment, which further
stigmatizes those seeking mental health treatment. When medically compromised patients seek
emergency care in the ER, they are quickly triaged, evaluated, treated, and dispositioned to
appropriate care. For a patient with mental health conditions, they are triaged, assessed, and
referred for specialized care but held in the ER until a proper disposition becomes available.
Although patients can be referred for inpatient or outpatient care, patients presenting safety
concerns are held until an inpatient psychiatric bed becomes available (Hsu & Chan, 2018).
People who are suicidal, homicidal, gravely disabled, or unable to care for their basic needs of
food, clothing, and shelter are most often held in the ER. These patients often languish in
desolate ERs monitored by security guards or sitters without their belongings and wearing only
gowns in the interest of safety. The ER physician and assigned nurse often lack the training to
evaluate and provide care to people with behavioral health issues, as they have minimal
education and training to treat this vulnerable population. Patients are often treated as a nuisance,
and to a patient in crisis, this only amplifies the crisis (Marciano et al., 2012; Nicks & Manthey,
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 7
2012; Zun, 2012). ER physicians can be quick to evaluate and medicate patients in crisis; thus,
leaving the patient sedated (Zun, 2012).
A disparity also exists for individuals with behavioral health issues, as they are not
transferred to the specialty required for immediate intervention. People with cardiac problems
are immediately transported to a medical floor, treated by a cardiologist and specialized team of
providers, and provided the most effective and efficient treatment required to expedite the
interventions prescribed. Mental health is the only condition for which specialized treatment is
not immediately available. Thus, care requires transfer to a designated treatment facility, but only
if or when a bed becomes available. Boarding in the ER has grown exponentially over the years
because of inpatient hospital closures, leaving fewer acute beds available and the ER as a last
resort for immediate safety. According to the Treatment Advocacy Center (2012) report, ERs
and jail or prisons are the alternatives for patients with mental health conditions because of
diminishing beds and outpatient options for care. ERs are impacted with patients often waiting
days to weeks only to be released without ever receiving mental health care (Treatment
Advocacy Center, 2012).
Inadequate supportive resources have been a problem for individuals with mental health
conditions since deinstitutionalization began in the 1960s. The community outpatient plans
initially intended to assist patients after being deinstitutionalized were never developed, leaving
many patients seeking emergent care in the ER (Allen, Forster, Zealberg, & Currier, 2002). In
California, the Lanterman-Petris-Short Act (LPS) was signed into law in 1967 “to end the
inappropriate, indefinite and involuntary commitments of persons with mental health
disorders…” (Welfare & Institutions Code, 2013, para. 2). The legislative intent of LPS is to
require prompt evaluation and access to treatment in designated LPS hospitals with judicial
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 8
oversight and protections for patient rights concerning due process (California Hospital
Association, n.d.; Welfare & Institutions Code, 2013). The LPS Act also designates where
patients can be treated; each county in California designates certain hospitals as LPS facilities,
which treats patients on an involuntary basis. However, a gap is evident in the LPS law, as it
does not state what happens to patients in the non-LPS hospitals, and therefore many patients are
held without the opportunity for due process or treatment while they wait involuntarily for
inpatient transfer to a designated facility (Stone et al., 2012). Further complicating the problem
according to Nolan et al. (2015) is the Emergency Medical Treatment and Labor Act (EMTALA)
and the issues it poses for patients and staff in the ER. The EMTALA directive is to evaluate,
stabilize, and transfer the patient for appropriate treatment (Centers for Medicare and Medicaid
Services, 2012; Zeller & Rieger, 2015).
The AASWSW established the 12 Grand Challenges, which are aligned with the World
Health Organization’s (WHO) health and wellness goals across the globe. The WHO developed
a mental health action plan promoting and improving research and evidence-based practices
(WHO, 2013). This action plan documented that “between 76 and 85 percent of people with
severe mental disorders receive no treatment for their disorder in low-income and middle-income
countries; in high-income countries the rate is between 35 and 50 percent” (cited in Bährer-
Kohler & Carod-Artalm, 2017, p. 4). Prevention and promotion strategies were highlighted by
Bährer-Kohler and Carod-Artalm (2017) as an opportunity to reduce stigma, which ultimately
decreases the likelihood people will access behavioral health treatment. Closing the health gap in
mental health will require systematically changing systems that have been in place since the
1960s, not only by improving access to treatment but also by altering where people receive
mental health treatment.
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 9
There have been only two levels of care when seeking treatment for mental illness:
inpatient and outpatient. Inpatient psychiatric hospitals and the number of beds across the United
States continue to decline (Stone et al., 2012; Treatment Advocacy Center, 2012). Outpatient
psychiatric treatment options have also declined because of decreased reimbursement rates from
insurance companies and budget cuts to outpatient mental health programs (Nesper et al., 2016).
It is essential to understand the context of the current mental health system to appreciate the
ongoing problem of psychiatric boarding. The population in the United States in 2015 was
320,090,857 (California Hospital Association, 2018) with 101,351 psychiatric beds for all states
in 2014 (Lutterman, Shaw, Fisher, & Manderscheid, 2017). Torrey, Entsminger, Geller, Stanley,
and Jaffe (2008) highlighted the need for at least one bed for every 2,000 people, which equates
to a severe deficit. In California, for instance, the population has increased by 7.6 million
between 1996 and 2016, but, within this same period, there has been a 28.3% loss of inpatient
beds or 2,651 due to closure (California Hospital Association, 2018). In 2015, the population in
California was 39,144,818 with only one bed per 5,922 people (California Hospital Association,
2018), which excludes state hospital beds. The severity of this deficit has left ERs overcrowded
and accounts for 21.5% of patients boarding on average for more than six hours (Nolan et al.,
2015). The average boarding times vary greatly and are dependent on the support in the
surrounding community. Zeller, Calma, and Stone (2014) reported boarding times that averaged
6.8 to 34 hours, even though the Joint Commission (2012) suggests that boarding should not
exceed four hours. Washington State’s length of stay (LOS) had become so pronounced that the
most extended boarding time documented in the ER was 100 days in 2012 (Appelbaum, 2015;
Bloom, 2015). It was found that 10 respondents had been boarded involuntarily, which prompted
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 10
legislation by the Washington State Supreme Court ruling boarding patients psychiatrically was
“unconstitutional and a violation of civil rights” (Miller, 2014, p. 18).
The implications of ER boarding on patients with mental health conditions include
increased LOS, increased stress on ERs impacting overall patient and staff satisfaction as well as
increased incidence of adverse outcomes and violence (Harris, Beurmann, Fagien & Shattell,
2016; Hefflefinger, 2014). Hospitals track LOS to gauge quality of care (Hsu, & Chan, 2018)
and costs savings (Desan, Zimbrean, Lee, & Sledge, 2014; The Joint Commission, 2015). The
costs associated with boarding quickly add up when patients are boarded for days (Bender,
Pande, & Ludwig, 2008). Negative attitudes and levels of discomfort by ER physicians and
nurses have been associated with the overuse of sedating medications with a patient with
behavioral health problems (Zun, 2012). When suicidal patients are identified, they are placed in
hospital gowns, stripped of their possessions, and monitored for safety (Bender et al., 2008;
Harris et al., 2016; Hefflefinger, 2014). Physicians in the ER are quick to evaluate the patient in
psychiatric crisis and defer to inpatient hospitalization and transfer with little regard for the level
of imminent danger to self and others (Stefan, 2006). In a study conducted by Stultz et al. (2015),
17% of patients referred for inpatient treatment were not thoroughly evaluated and ended up
being subsequently discharged by behavioral health staff following proper assessment. Further
complicating matters, patients are boarded without treatment. According to Applebaum (2015),
62% are not receiving any psychiatric treatment in the ER. Further psychiatric patients often do
not receive their routine psychotropic medication, leading to further decompensation followed by
increased use of sedating medications and restraints (Bender et al., 2008; Hefflefinger, 2014;
Zun, 2012).
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 11
Weiss et al. (2012) found that LOS is increased for people with behavioral health
concerns. Further, Misek, Magda, Margaritis, Long, and Frost (2017) highlighted the subsequent
burden the ER incurs as a result of bed closures in the community, which were found to be
dependent on the local outpatient resources available in the community (Misek, DeBarba & Brill,
2015). Other factors affecting LOS include the type of health coverage or lack of coverage
(Misek et al., 2015; Smith et al., 2016). The day of the week also affects access to inpatient beds
as many insurance companies authorize patients to remain inpatient in psychiatric hospitals
through the weekend; thus, fewer beds are available to new patients on the weekends (Stephens
et al., 2014).
Comprehensive data is needed to determine the true extent of ER boarding of psychiatric
patients on a larger scale than what has been acquired thus far (Alakeson et al., 2010;
Appelbaum, 2015; Bender et al., 2008; O’Neil, 2016). The mental health system is in dire need
of a transformation, and while research has been conducted on this problem, it lacks large-scale
populations across the United States (American College of Emergency Physicians, 2014; Bender
et al., 2008; Hsu, & Chan, 2018; Misek et al., 2015). The research has highlighted the need for
innovations in behavioral health (Bender et al., 2008; Zeller et al., 2014; Zeller & Rieger, 2015).
Some research has focused on improving access to inpatient beds (La et al., 2016), whereas other
researchers are focused on developing alternative solutions (see Figure 1 for Comparative
Analysis) to improve access to mental health care and decrease ER boarding by developing
Crisis Stabilization Units (CSU), offering short-term crisis intervention in LPS-designated ERs
(Zeller, 2010; Zeller & Rieger, 2015). Recommendations have been made for implementing
telepsychiatry services and having licensed behavioral health clinicians in the ER to assist in
further evaluating patients (Zeller & Rieger, 2015). Additionally, 24 hours of urgent psychiatric
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 12
care or regional PES have also been recommended to decrease ER boarding (Zeller & Rieger,
2015). The PES is a freestanding facility offering patients an alternative to the ER. Patients are
provided immediate evaluation and treatment for up to 24 hours, as they are staffed with
behavioral health care providers. Mobile crisis teams have been developed to include mental
health clinicians who meet with patients in the community and provide immediate crisis
intervention and resources to help de-escalate the crisis (Zeller & Rieger, 2015). Crisis
Intervention Teams (CIT) train police and first responders in crisis intervention by pairing them
with mental health clinicians to evaluate people in the community to de-escalate the crisis and
refer to the most appropriate resources rather than jail or hospitals (Cuddeback, Kurtz, Wilson,
VanDeinse, & Burgin, 2016; Tully & Smith, 2015). In San Diego, CA, the Psychiatric
Emergency Response Team (PERT) includes law enforcement and a licensed mental health
clinician who evaluates patients when 911 is activated for a psychiatric emergency in the
community (Rodriguez, 2016). Despite these mobile teams working to address the crisis in the
community, no other multidisciplinary mobile teams have been formed to address the psychiatric
crisis in the ER.
Peer support specialists are another essential component to mental wellness according to
the Substance Abuse Mental Health Services Administration (SAMHSA, 2017). Forchuk,
Martin, Chan, and Jenson (2005) discussed the use of a transitional discharge model that
included peer support following hospital discharge to promote continuity of care until patients
engage with outpatient providers. Peer supportive services were also highlighted by Chinman et
al. (2014) as an extension to mental health services, insurance plans to help individual consumers
and families navigate the broken mental health system. Landers and Zhou (2011) reported that
peer support services correlate with decreased episodes of crisis and psychiatric hospitalizations.
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 13
The goals of psychiatric emergency treatment, as documented in Zeller (2010) and Zeller
and Rieger (2015), are to ensure medical stability, de-escalate the crisis, provide treatment in the
least restrictive level of care offering a noncoercive, therapeutic alliance, and establish plans for
continued treatment in the most appropriate level of care. Zeller et al. (2014) discussed the
behavioral health team approach offered in a stand-alone regional PES available to patients in the
community 24 hours a day on a walk-in basis. The PES accepts drop-offs from law enforcement
and transfers from surrounding ERs, also known as the Alameda model, which offers immediate
crisis intervention and reported higher rates of discharge to lower levels of care compared to no
treatment while being boarded in the ER (Zeller et al., 2014). Zeller (2017) also highlights the
utilization of an Emergency Psychiatric Assessment, Treatment & Healing unit or emPATH
model, which are being developed to help give patients the space they need to promote mental
wellness in the form of an open living room space with soft lighting, soothing colors, and
tranquil murals on the walls. The lounge chairs recline for individuals who would like to rest and
are movable to accommodate therapy groups. Staff and patients comingle in the space,
preventing a fishbowl atmosphere dividing patients and staff. The need for such integration of
care was highlighted by Summergrad and Kathol (2014). They reported that people with and
without severe mental illness tend to seek care in the general ambulatory medical setting, which
segregates services and medical records that do not follow the patient across sectors and impacts
the comorbid issues and increases the cost of caring for the patient (Summergrad & Kathol,
2014). The available programs in the community are integrated into one program that makes up
the MPTT:
• Treatment at the ER/hospital site up to 23 hours and 59 minutes
• Inpatient interdisciplinary mobile team, including peer specialists
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 14
• Crisis intervention, safety and medication consultation/management
• Providing case management for up to 30 days post discharge
Theory of Change and Logic Model
To decrease the incidence of ER boarding, new treatment options will need to be
developed as an alternative to inpatient hospitalization (Nesper et al., 2016). The innovation of
the MPTT will utilize the emPATH model (Zeller, 2017) in LPS and non-LPS hospital settings
to treat patients immediately. The MPTT will be piloted at one ER in San Diego, CA for one
year. A designated space within the hospital will house the MPTT staff and patients once
determined medically stable to transfer from the ER. A psychiatrist or psychiatry resident will be
available 24 hours a day, seven days a week to accept patients and will oversee all treatment and
patient care. Patients will be provided face-to-face evaluations virtually or in person within the
first four hours of the patient’s arrival to the unit by the psychiatrist or resident. Medication
consultations for psychotropic medication will allow patients to be started or restarted on
medication if needed. The PRN, SW, and MHW will provide 24-hour care to patients while on
the unit. This pilot will run 24 hours a day for 12 months beginning on October 1, 2019 through
September 30, 2020. The goal is to provide MPTT services to 1,825 patients in 12 months or an
average of five people per day. Patients will no longer have to wait to transfer to care. The goal
is to work with the patient in a therapeutically appropriate setting to de-escalate and connect
them to their support systems in the community while preparing for discharge and linking them
to follow-up psychiatric care in the community. Each patient discharged from the unit will
continue to benefit from ongoing case management provided by the team for up to 30 days to
help ensure they are established with providers on an outpatient basis (see Table 1 for Logic
Model).
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 15
The resources and inputs required to implement this program include identification of
revenue sources, such as applying for grants and presenting to potential funders. Collaborations
and partnerships will be developed with local universities, hospitals, and the County of San
Diego. The needs of the surrounding community will be assessed by engaging community
members and local political figures. Additional inputs include developing a social presence on
social media and in the community as well as developing a website to draw media attention to
the problem and solution being presented. The author will be presenting at BeHealth.Today as an
opportunity for potential county funding. Once a hospital system has been identified, the MPTT
unit site will be defined within the hospital setting and staff will be hired.
The activities include providing mental health treatment to adult patients who seek care
in the ER. The team will monitor the patients for safety for the duration of their stay on the unit.
The treating psychiatrist will evaluate each patient and provide consultation for medication as
needed. Peer support specialists will be available to help engage patients during their stay. Once
patients are discharged from the MPTT unit, each patient will have access to the team for up to
30 days to assist with reestablishing care with outpatient providers, medication management, and
ongoing support to decrease readmission to the ER.
The outputs include serving 1,825 patients annually by providing 24-hour care by the
MPTT staff during the one-year pilot program. Each patient will have 23 hours and 59 minutes
on the MPTT unit and will continue up to 30 days post discharge for case management services.
The short-term goals include patients receiving immediate mental health treatment in the
hospital setting. Patients will be seen virtually by the psychiatrist and will have access to the
mental health team in person to help address their immediate psychiatric needs. Patients will be
discharged to appropriate levels of care within 24 hours. Ultimately, patients will be connected to
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 16
outpatient resources with follow-up and support for up to 30 days to help navigate the mental
health system once they leave. Finally, the implementation of the MPTT will improve the flow in
the ER because patients will no longer be waiting for transfer to receive specialized treatment.
Table 1
MPTT Logic Model
Resources/Inputs Activities Outputs Short-term
Outcomes
Long-term
Outcomes/Impact
• Develop
Partnerships with
University and
hospital system
• Develop
collaboration
with the County
of San Diego
• Apply for
eligible grants &
funding
• Present at
BeHealth.Today
• Identify the
needs of the
surrounding
community of the
ER
• Identify space for
the MPTT unit at
hospital
• Hire staff
• Provide mental
health
treatment for
adult patients
• Monitor patient
safety
• Provide
medication
consultation
and evaluation
• Provide peer
support
• Provide case
management
services

• Serving 1825
patients in one
year

• Patients treated
up to 23 hours
and 59 minutes

• Provide each
patient
discharged
case
management
services for up
to 30 days

• Increased
access to
mental health
services in the
ER
• Mental health
professionals
treating
patients’
immediate
psychiatric
needs
• Patient’s
discharged
within 24 hours
• Patient’s linked
to community
services and
providers
• Patients have
MPTT
navigational
support up to
30 days
• Improved ER
flow
• Increased patient
satisfaction
• Decreased
incidence of ER
boarding
• Increased
hospital revenue
• Readmissions to
ER within 30
days decreased
• Cost savings for
hospitals,
insurance
companies and
overall health
care
• Increased equity
in mental health
care
• Decreased stigma

The long-term goals of the project will be to ultimately decrease and eliminate ER
boarding of patients with mental health problems and decrease the unnecessary transfer and
admission of patients to inpatient hospitals. Patient satisfaction will improve because the
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 17
treatment will be available immediately. With a decrease in boarded patients in the ER, the
hospital revenue will increase and overall cost savings to hospitals, insurers, and overall
healthcare. There will also be decreased readmission rates within 30 days because patients will
be supported with aftercare navigation for continued treatment. There will also be increased
equity in mental health care, which may also reduce stigma.
Problems of Practice and Innovative Solutions
The innovation proposed to address the GCSW to Close the Health Gap is the
development of the MPTT. The development and implementation of this team will solve the
crisis of ER boarding by improving access to mental health services at the source of entry while
decreasing the disparity and inequity of care (Spencer et al., 2018; Walters et al., 2016) by
bringing the right treatment at the right time. For many people, the ER is the only available
option for patients in mental health crisis, as it is available 24 hours a day. This proposal is
innovative because it provides inpatient psychiatric treatment, crisis intervention as well as
disposition and referral planning utilizing tele-psychiatric capabilities to patients who would
otherwise be held in the ER without treatment for more than 24 hours awaiting transfer for
specialized services.
What makes the MPTT unique is the 23 hour and 59-minute time frame in which the
team must stabilize and determine a plan for continued care by either discharging to a lower level
of care or transferring the patient for inpatient psychiatric hospitalization. Continuity of care will
also continue after discharge. Patients will continue to have access to the team for up to 30 days
to assist in the transition to outpatient providers in the community via telepsychiatry services for
medication management and case management needs. By addressing the current gaps in the
mental health system as well as addressing and coordinating care, the innovation addresses
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 18
prevention and facilitation of the care transitions for a vulnerable population, which according to
Browne et al. (2017) is the proposed solution to close the health gap.
Another strategy proposed to close the health gap is by integrating the triple aim
philosophy and behavioral health (American Hospital Association, 2016). The American
Hospital Association (2016) put forth a call to action by proposing hospitals and health care
systems improve integration of services for both medical and mental health. They also
highlighted building connections with stakeholders in the community to ultimately decrease the
cost of healthcare (American Hospital Association, 2016). The transition from a segregated
mental health model of care, in which patients are required to seek specialized facilities, to an
integrated model of health care promoting total wellness mind and body will help to eliminate
the stigma of help-seeking behaviors (Bährer-Kohler & Carod-Artalm, 2017). Utilizing the
WHO action plan, the triple aim, and care integration, the MPTT will be leading
transformational change within a complex, yet broken, mental health system.
Cultivation of stakeholders will be required to implement this program, which challenges
the norm of the mental health system in the United States. Those who are closest to the problem
include consumers, their families, physicians, nurses, hospital administrators, community
providers, and the public. Interviews were conducted with users and experts in the field who
work with patients and their families. The responses from a psychiatric nurse who evaluates
patients in the ER suggested the local mental health system in San Diego is complex and many
people do not know where to start, so they end up in the ER. It was also suggested that
collaborations between levels of care improve to prevent immediate readmissions into the ER (K.
Harper, RN. personal communication, October 14, 2018). Additional feedback provided by S.
Kelleher (personal communication, October 13, 2018), a clinical trials specialist and program
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 19
manager of an early episode clinic in San Diego identified that many patients are traumatized by
the lack of respect by ER staff. Patients are stripped of their belongings, forced to wear hospital
gowns, and monitored by security, which labels them as a psychiatric patient and further
stigmatizes seeking mental health care. It was also suggested that patients with multifaceted
mental health conditions need swift interventions to de-escalate the problem (S. Kelleher,
personal communication, October 13, 2018). A psychiatrist in the community suggested the need
to collaborate with families and friends when patients are in crisis to help determine safe
discharge plans (C. Dang, MD, Psychiatrist, personal communication, October 12, 2018). The
previous director of the PERT in San Diego, CA. and current manager of the Psychiatric
Evaluation Team at Sharp Healthcare suggested that the county must have 24-hour programs to
address the complex needs of individuals with mental health conditions. He suggested patients
with mental health issues should be provided the same respect and dignity as patients with
medical conditions (J. Fix, Ph.D., personal communication, October 14, 2018). The clinical
district chief of the Department of Mental Health Services, California stated that before
implementation, it is imperative that there is community input from the surrounding community.
It was also recommended that providers engage with the community to develop a network to
connect high utilizers of ER services with appropriate community programs. It was further
established that by improving programs available 24 hours a day, this would not only decrease
the need for people to seek ER treatment but also reduce the need for inpatient hospitalization
(M. Marx, LCSW, personal communication, July 27, 2018).
The ER is not an appropriate setting for consumers seeking mental health treatment but is
often found as a last resort. Consumers and their families have reported being frustrated with the
lack of treatment options available for mental health treatment. Harris et al. (2016) conducted a
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 20
study to determine patient experiences in the ER, and three themes were identified, “Emergency
rooms are cold and clinical, they talk to you like you are a crazy person, and you get put away
against your will” (p. 16). In a more recent study conducted by Thomas et al. (2018), patients
expressed comfort, shared communication, and respect as the most critical attributes to crisis
care, which often are neglected in the ER setting.
Other stakeholders include politicians, community leaders, oversight agencies, insurance
companies, and community and state level organizations. Fostering collaborations with these
stakeholders will ultimately help to stabilize the crisis that has developed in the ER, which has
continued to grow since the initiation of deinstitutionalization. The implementation of this
innovation will contribute to the GCSW and closing the health gap, which mirrors the WHO’s
2013 to 2020 goals and action plan to improve mental wellbeing in every country around the
world (Bährer-Kohler & Carod-Artal, 2017). The WHO action plan documented that 76% to
85% of individuals with mental health disorders in low- to middle-income countries do not
receive treatment (Bährer-Kohler & Carod-Artalm, 2017). The research has highlighted that
many medical schools do not provide mental health training for general practitioners, which
hinders their ability to treat patients because they lack the basic knowledge of how to care for
individuals with mental health conditions (Rodriguez et al., 2009 as cited in Bährer-Kohler &
Carod-Artal, 2017). Zun (2012) discussed the disparity seen in patients who seek treatment in the
ER versus those without medical conditions. According to Bährer-Kohler & Carod-Artal (2017),
mental health stigma is a problem occurring universally and in need of resolution.
The solution the MPTT innovation seeks to eliminate ER boarding by providing crisis
intervention to the patient in a nonstigmatizing setting. As history reveals, deinstitutionalization
offered hope of independence and community support for people living with mental health
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 21
conditions; however, the structure to provide housing, outpatient programs, and funding was
never fully established to meet the needs of this vulnerable population (Allen et al., 2002).
Mental health has caused tension politically since deinstitutionalization, as the federal
government has established firm lines financially requiring the state to pay for mental health
services. Examples of this division are the Medicare and Medicaid systems of care preventing
comprehensive psychiatric services to all people. Until recently, the federal government
stipulated that Medicaid paid for by the states was to be the primary funding source for patients
ages 21 to 64, “prohibiting Federal Medicaid matching” (California Hospital Association, 2016,
p. 6), also known as the Institute of Mental Disease (IMD) exclusion. Congress recently repealed
the outdated IMD exclusion with the IMD Cares Act highlighted in Section 5051 and 5052 of the
115th Congress of the United States. The repeal allows states to make the amendment granting a
reprieve to certain treatment centers to provide mental health and substance abuse treatment to
people between the ages of 21 to 64 under Medicaid (Senate and House of Representatives of the
United States of America in Congress, 2018). This temporary repeal will begin October 1, 2019
and be in effect until September 30, 2023, allowing outpatient, inpatient, and residential
treatment services to Medicaid recipients in certain IMD facilities for up to 30 days (Senate and
House of Representatives of the United States of America in Congress, 2018).
Further restrictions set by the federal government for individuals who have Medicare
include the limitations of 190 lifetime days for freestanding hospitalizations. Medicare limits
where patients can receive mental health treatment by allowing only 190 days in freestanding
psychiatric hospitals. Once a patient exhausts their lifetime days, they are then subject to the
IMD exclusion, which limits their ability to be treated in freestanding facilities and further
impacts ER boarding (The Official U.S. Government Site for Medicare, n.d.). Federal restrictions
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 22
on psychiatric treatment continue to contribute the fragmentation of the mental health system
because current mental health treatment does not meet the expanding growth of new mental
health diagnoses (Scarbrough, 2018).
The mental health system in California, as in the rest of the nation, has identified that
more people are seeking psychiatric treatment in the ER (Hospital Association of San Diego &
Imperial Counties [HASDIC], 2017). The HASDIC stated the ER had been the “first resort in
many communities” (HASDIC, 2016, para 2). A needs assessment was completed in 2016 and
the HASDIC (2016) identified that between 2012 and 2015 the number of patients with a
primary psychiatric diagnosis sought care in the ER increased from 34,500 to 43,200. Moreover,
the cost out-of-pocket to consumers with mental health conditions is “the highest of any chronic
condition” (Reifsnyder & Yeo, 2011, p. 71). With the cost of labor, advancement of technology,
and increased regulatory pressures placed on hospital systems, hospital administrators have been
encouraged to seek cost-effective strategies (HASDIC, 2017).
The MPTT is well positioned for implementation in San Diego, CA. Given the history,
current policies, and practices, the landscape is ripe for innovation, especially in mental health.
The shortage of inpatient psychiatric hospital beds in San Diego County is severe, so the county
has been working to establish goals to improve outcomes and use resources more efficiently
while implementing person-centered care (HASDIC, 2017). The County of San Diego Health
and Human Services Agency (CSDHHSA, 2018), in accordance with the Mental Health Services
Act (MHSA), has budgeted $13,250,247 for the fiscal year 2018–2019 for innovations in
behavioral health services and has proposed a 10-year ‘road map’ that includes the development
of innovative collaborations to address community safety and ER boarding. The strategy
suggests access to improved interventions to reduce the need for law enforcement and ER
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 23
services with a focus on peer and family interventions to drive crisis intervention as well as the
development of crisis intervention at any point in the continuum of care (CSDHHSA, 2018). The
CSDHHSA also seeks to improve mental health innovations by developing a ‘human-centered
redesign’ where community stakeholders encourage the development of innovations and provide
funding to improve the system of care. One of the innovations in line with the MPTT innovation
is incorporating tele-mental health with the goal to “promote access, reduce disparities, decrease
recidivism, and increase the effectiveness of follow‐up engagement and treatment” (CSDHHSA,
2018, p. 31). The current programs in San Diego include mobile Psychiatric Evaluation Teams
(PET), which consist of licensed mental health clinicians who evaluate patients in the ER as a
service to the ER. The CSU offers short-term crisis intervention situated in an LPS facility. The
CSU is the closest to the MPTT; however, the MPTT is mobile and is able to provide treatment
in every ER, including LPS and non-LPS facilities. Currently, the CSU is only available in one
ER in the county for adults and one for children, and they transfer patients from their own ERs to
decrease boarding.
The MPTT currently aligns with the 2019 priorities according to the HASDIC, which
include improving access to health care, behavioral health, and services in the ER (HASDIC,
2019). Research indicates when patients are provided with immediate behavioral health
treatment, many of them can be discharged within 24 hours without inpatient transfer (Hsu &
Chan, 2018; Weiss et al., 2012; Zeller, 2013; Zeller et al., 2014). Furthermore, Zeller and Mao
(2016) determined PES programs were more cost-effective for insurance companies compared
with ER boarding and hospitalization. By developing the MPTT, the program will bring the
inpatient psychiatric treatment team to the patients who would otherwise be held without
treatment in the ER. The MPTT will address ER boarding of patients with mental health
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 24
conditions and provide patients treatment, instead of waiting for transfer for specialized
treatment and care. The opportunities for the implementation have been carefully considered.
This author will be presenting a proposal for the MPTT on April 4, 2019, as part of the County
of San Diego Health and Human Services Agency, MHSA 2019 Human-Centered Design by
BeHealth.Today conference to secure funding to launch this program.
Project Structure and Methodology
The artifact developed is in the form of an unsolicited proposal (see Supplemental
Material) to be submitted to the University of California San Diego (UCSD). The phases of
intervention for the MPTT include an intake and evaluation phase, treatment and safety phase,
and discharge and follow-up phase. The MPTT phases of intervention are further delineated in
the MPTT workflow from the time of entry into the ER to the time of discharge from the MPTT
unit (see Figure 2 in Appendices). The ER registered nurse (RN) will triage patients who seek
emergency mental health treatment in the ER. The ER physician will evaluate and medically
stabilize the patient. If the ER physician identifies a mental health condition requiring further
stabilization, the physician will refer the patient to the MPTT. The ER staff will place a call to
the MPTT intake line. The MPTT staff on the intake line will review the electronic health record
(EHR) and hospital documentation and present the case to the psychiatrist on call. At this time,
the psychiatrist will decide whether to admit the patient to the MPTT unit for transfer. The
patient will remain in the ER until the MPTT arrives at the hospital. The MPTT intake staff will
then deploy the MPTT PRN, MHW, and SW with the goal to arrive at the ER within 30 minutes.
The PRN will receive the verbal handoff from the ER RN and will transport the patient to the
MPTT unit within the hospital. The PRN, MHW, and SW will evaluate the patient upon
admission to the MPTT unit. The patient will be offered an electronic tablet or IPAD, which will
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 25
be provided in English and Spanish for the pilot, to complete the clinical self-report measures
preloaded on the tablet. If a patient cannot complete the questionnaire for any reason, the
questions may be administered verbally. According to Section 5778 of the Welfare and
Institutions Code, a psychiatrist must be on call 24 hours a day, and for the purposes of the
MPTT, will be available virtually to evaluate the patient within the first four hours for initial
psychiatric evaluation, medication consultation, and treatment planning (California Code,
Welfare Institutions Code, 2012).
The treatment phase will consist of therapeutic activities as well as individual, family,
and group sessions utilizing the Wellness Recovery Action Plan [WRAP] (Copeland, 2002). The
SW will work with the patient to identify any immediate needs and provide intensive crisis
intervention and solution-focused therapy. The SW will discuss resources, available support, and
engage family and friends in the treatment plan to coordinate discharge and follow-up care. The
MHW will work with the patient on the WRAP, and the team will provide supervision and safety
monitoring for the duration of the patient’s stay. The PRN will be available to provide
medication as needed while the patient is on the unit.
The discharge phase begins immediately at the time of admission and continues
throughout the patient’s stay. The PRN will conduct a 12-hour nursing assessment, and the team
will consult with the psychiatrist to finalize discharge plans. The outcome of this 12-hour
assessment will provide one of two paths. The first path is that the patient is determined to be
safe to discharge to a lower level of care. In this case, the SW will meet with the patient and
establish outpatient appointments, provide resources, and discuss transportation from the unit to
the next level of care. The SW will engage the patient’s support system in the discharge plans
with patient consent. The patient will develop a safety plan before discharge and have the WRAP
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 26
for continued support. The patient will then meet with the psychiatrist virtually for final
evaluation and discharge within 23 hours and 59 minutes. After the patient discharges, the
patient will have access to the MPTT by telephone for up to 30 days. The SW will contact the
patient at day three and day seven to provide continued support post discharge and will remain
available to the patient as needed for up to 30 days post discharge from the MPTT unit to
continue to assist the patient with follow-up care with outpatient providers to decrease
readmission to the ER. The second path after the 12-hour nursing assessment includes the patient
who requires longer stabilization and is meeting criteria for an inpatient psychiatric
hospitalization. The psychiatrist will evaluate the patient and place an order for the patient to
transfer to a higher level of care. The PRN will then call for bed availability in the community
and begin the referral process. The MPTT staff will continue providing ongoing treatment and
safety monitoring until the PRN secures a bed for the patient and ambulance transport is
arranged. The patient will then transfer to the inpatient hospital within 23 hours and 59 minutes.
Local Landscape
The MPTT will pilot at one hospital in San Diego, CA to address the gap of mental health
services in hospital ERs. Due to a lack out outpatient resources, patients tend to have nowhere to
go for immediate care until they are in crisis. Currently, there are two CSUs in San Diego with
one for adults at Palomar Hospital and one for children at Rady Children’s Hospital. Both CSU’s
are attached to LPS hospital sites and do not cater to the community. Admissions to the CSU
program are limited to referrals within their system. The CSU is a dedicated space where a
behavioral health team provides supervision and care to patients who might otherwise languish
in the ER while awaiting appropriate inpatient transfer or safe discharge. All hospital ERs in San
Diego have licensed mental health clinicians who evaluate patients with mental health concerns;
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 27
however, due to the number of patients in the ER seeking mental health treatment, there is
neither the time nor resources to provide treatment in the ER setting. In the community, there is
the PERT or police who transport patients to the ER who need involuntary evaluation. The
County of San Diego has walk-in crisis clinics around the county, but patients may spend hours
waiting for evaluation and may need to return another day because people are seen in order of
acuity. One major issue is that these clinics are open only Monday through Friday from 9 AM to
5 PM and closed on holidays and weekends. Mental health conditions persist without regard to
business hours and patients are encouraged to go to the ER for immediate help. One of the
county clinics, the Jane Westin Center, in downtown San Diego recently extended its hours for
walk-in care from 8 am to 10 pm, seven days a week. In San Diego, UCSD developed a
Transition and Rapid Access Clinic (TRAC), which provides short-term case management by
psychiatric nurse practitioners to help stabilize nonacute psychiatric patients after discharge from
the ER. Despite these options for mental health care, they are patched together at each system of
care. The gap in the system remains for patients in the ER in need of short-term acute mental
health treatment. The MPTT focuses on patients in the ER requiring mental health treatment in a
secure and safe setting with supervision allowing voluntary and involuntary patients mental
health treatment and stabilization.
Implementation Strategy
The strategy proposed to implement the MPTT utilizes the expert recommendation for
implementing change (ERIC) model (Brownson, Colditz, & Proctor, 2017; Powell et al., 2012;
Powell et al., 2015). The ERIC framework will be used to plan the MPTT strategy to engage
hospitals and identify critical stakeholders surrounding the areas to determine the specific needs
within the community (Powell et al., 2012; Powell et al., 2015). It is imperative to recruit leaders,
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 28
identify collaborations, and build partnerships to develop memorandums of understanding
(MOU) for implementation. The strategy for education (Powell et al., 2012; Powell et al., 2015)
will be to develop and disperse facts about the current crisis in the county as well as across the
nation. To engage stakeholders, social media will be used to highlight the problem and potential
solution. Training programs at the hospital and community workshops will be developed to
provide education on the MPTT to ensure it meets the needs of the people most affected
surrounding the ER where the pilot will be launched. Training and workflows will be developed
for hospital staff and providers to address the needs of the physicians, RNs, and staff in the ER.
Obtaining data from stakeholders will be an asset in managing quality care. By utilizing
an EHR, data will be collected and provide prompts to ER physicians and staff to help ensure
expedited referrals to the team. Upon implementation, the MPTT leadership will establish a
centralized guidance center to provide help to the staff in the ER for seamless referral and
transitions to the MPTT program.
The implementation strategy for the MPTT program will use the exploration, preparation,
implementation, and sustainability (EPIS) framework by Aarons, Hurlburt, and Horowitz (2011).
Utilization of the EPIS framework allows for the identification of potential facilitators and
barriers during each stage of implementation that may require attention (see Table 2 for EPIS
implementation model). The exploration phase tasks will include conceptual project
development, research, and projections for associated costs for staffing and impact. The
preparation phase will consist of risk assessment, partnership development, and program
organization layout. The plan is to develop a stakeholder engagement plan and a network of
community organizations from both the public and private sectors to encourage partnerships and
to engage political leaders to assist in the development of the MPTT program. The
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 29
implementation phase highlights the plan for funding the MPTT program and procuring the
funds required for implementation. The MPTT plans to collaborate with a local university in San
Diego. There have been two potential partners identified: UCSD Community Psychiatry Program
and the San Diego State University (SDSU) Social Policy Institute. Both universities offer
opportunities to produce quality research in behavioral health. UCSD has two ERs in San Diego
along with an LPS hospital and outpatient psychiatry programs, it is associated with the medical
school and can assist with pursuing grants (A. Roeschlein, personal communication, March 2,
2019). The SDSU Social Policy Institute focuses on community development and engaging
innovations in support of the Healthy People 2020 goals, it is connected to BeHealth.Today and
is able to assist with pursuing policy and advocacy support as well as grant funding (S.
Hornberger, personal communication, March 10, 2019). The team will contract with private and
public insurance companies to bill for crisis intervention services. Permits and licensing will be
obtained with the Department of Health Services (DHS). Finalizing the costs and budget as well
as configuring the designated space for the MPTT, hiring and training staff, furnishing, and
installing technology will be required during this phase. The final stage of sustainability includes
monitoring the MPTT performance and outcomes to ensure objectives are being met. Tracking
the costs of the program, quality of program delivery, and performance goals will be imperative
to the MPTT’s sustainability as well as projecting future performance.
Exploration Phase
Using the EPIS framework, the facilitators and barriers will be discussed within each
phase of implementation. Concerning the exploration phase, outer context barriers include the
current political administration changes to the Affordable Care Act for providing mental health
and treatment for addiction and authorizing states to determine essential healthcare benefits
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 30
(Centers for Medicare & Medicaid Services [CMS], 2018). The LPS Act limits treatment
locations for mental health conditions and does not offer guidance for non-LPS facilities
(California Hospital Association, n.d.). Collaborations and partnerships will need to be
developed with an established nonprofit entity. Funding remains the ultimate barrier, as it has
been reported when outpatient treatment options and inpatient beds decrease, the ER access
increases (Nesper et al., 2016). To facilitate this barrier of funding and to implement the MPTT,
leadership plans to identify and apply for available grants.
Table 2
EPIS Model Implementation: Barriers and Facilitators
Exploration Outer Context
• Barriers: Political climate, laws & regulations, funding
• Facilitators: Alternatives to ER & hospitalization
Inner Context
• Barriers: Untrained staff, staff attitude, social network, funding
• Facilitators: culture, climate, leadership, staff values & goals, perceived need
for change, development of the mission & vision
Preparation Outer Context
• Barriers: LPS designation
• Facilitators: Medicaid expansion, diverse revenue source, partnerships,
advocates, applying for grants
Inner Context
• Barriers: Organizational size, structure/knowledge
• Facilitators: Organizational size, values, leadership
Implementation Outer Context
• Barriers: Missed trainings
• Facilitators: Funding, multiple trainings, leaders
Inner Context
• Barriers: Structure, distance between sites, level of bureaucracy, attitude
• Facilitators: Mission & vision, attitude, culture, climate, leadership
Sustainment Outer Context
• Barriers: Funding
• Facilitators: Leadership, competitive benefits, audits, feedback, educational
collaborations
Inner Context
• Barriers: Funding, leadership, collaborations, feedback, evaluation, fidelity
• Facilitators: Leadership, collaborations, feedback, evaluation, scaling, fidelity

CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 31
Within the outer context of the exploration phase, the facilitators to the implementation
process include identification of alternative options to alleviate the barriers noted above by
working with hospitals and politicians to update existing laws and regulations. In Washington
State, ER boarding had become such a problem that the Supreme Court in Washington State
ruled that boarding is a violation of patients’ rights and unconstitutional (Appelbaum, 2015).
Psychiatric inpatient beds continue to close, without options for patients who need acute care.
Notably, an increase in the number of inpatient beds is not the answer because many people do
not require this level of attention but rather immediate acute care. Zeller et al. (2014) reported
that many crises could be resolved within 24 hours if they are treated immediately and this is the
level of care missing in many ERs.
The extent of ER boarding on a national level is the main barrier of the inner context in
the exploration phase (Alakeson et al., 2010). The characteristics of the pilot hospital setting
most impacted by the problem are the lack of trained ER physicians, nurses and staff are not
adequately trained to treat patients presenting with mental health conditions, and ERs that lack
the resources to appropriately treat and stabilize patients requiring acute care (Boudreaux et al.,
2016; Marciano et al., 2012; Zun, 2012). There is a perceived need for change within the hospital
setting (Aarons et al., 2011) by ER physicians and hospital administrators. The medical and
psychiatric fields are loosely connected, and this is another barrier to improve, as there will need
to be a universal language developed between the interdisciplinary teams to implement the
MPTT program. The mission and vision of the MPTT drive this phase of development. The
mission of the MPTT is to bring mental health treatment directly to the patient in the community,
ensuring dignity and respect in a nonstigmatizing setting while ensuring safety at the least
restrictive level of care. The vision of the MPTT is the promotion of mental wellness and
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 32
building connections to ensure a healthier generation. The exploration phase, inner context
facilitator includes developing an MOU with an LPS hospital site, such as UCSD, which has an
established research and psychiatry department.
Preparation Phase
The barrier identified in the preparation phase of the EPIS model in the outer context is
the sociopolitical barrier of the LPS designation. The LPS designation does not guide the non-
LPS hospital systems, which prevents patients from receiving due process. The facilitators in the
preparation phase of implementation include the Medicaid expansion program in California that
allows low-income individuals access to health coverage. The MPTT plans to seek funding from
diverse funding sources, which include fee-for-service reimbursements from insurers,
collaborations with hospitals and universities, and funding from donations and grants. Slow
payment from fee-for-service reimbursements and appropriations of grants and donations are the
barriers to this funding, whereas developing partnerships will assist with in-kind contributions to
offset costs for the space needed to house the program within the hospital. In preparation for
implementation, application for available grants will be submitted to support initial costs of
implementation. The preparation phase facilitators include seeking community special interest
organizations to join the collaborative as advocates to represent stakeholders and peer support to
assist in sustaining the MPTT program. The organizations include both national and local
chapters of the National Alliance on Mental Illness (NAMI) in San Diego, the Jewish Family
Services Patient’s Advocacy Department, and the County of San Diego Department of
Behavioral Health.
The preparation phase, inner context barriers, and facilitators include the size of the
hospital the MPTT is integrating, as well as the structure and characteristics of the leadership
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 33
values and beliefs. Many medical facilities are unfamiliar with psychiatric practices and laws,
and this could become a barrier unless education is provided to help facilitate their understanding
of the requirements. Continuing Education Units may be used to focus on educating the hospital
staff working within the system about the processes and the benefits of the implementation.
Training and workshops in person and virtually will be utilized for the stakeholders as well as
hospital and MPTT staff. Obtaining information from stakeholders throughout the
implementation process will help the MPTT leadership address identified needs.
Implementation Phase
The outer context of the implementation phase will require training and the development
of written policies and procedures. Administrative meetings with hospital leadership and ER
physicians will need to occur to provide education on the workflow and continuity of care.
Barriers at this stage include key stakeholders missing meetings and trainings. Organizational
leaders will need to also facilitate the process by “promoting a positive implementation climate,
attitude, and readiness for implementation” (Aarons et al., 2011, p. 13).
The inner context facilitators of the implementation phase include obtaining permits and
licensure to operate. A barrier to consider is the distance between hospitals, as the team is mobile
and will be traveling to each hospital to provide services. Palinkas and Soydan (2012) reported
the leadership, climate, and culture within the organization can be either a barrier or facilitator
for the implementation of new programs. It was highlighted by Aarons (2004) that staff with
greater experience within an organization may be resistant to change, but this can be facilitated
by newer staff who may be willing to engage in the change process.
Sustainability Phase
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 34
The final stage of the EPIS model is the sustainability phase, for which the leadership
team and policies implemented are important facilitators within the outer context. Funding may
continue to be a barrier during this phase, as it is vital to remain competitive within the market
not only in benefits and wages but also in technology advances (Bedsworth, Goggins, &
Howard, 2008). Budget monitoring and incorporating internal and external audits and evaluation
will facilitate sustainability, growth, and expansion of the MPTT program. Continuously seeking
new funding sources, grants, and collaborations with universities to conduct research and publish
results from the outcomes will facilitate future funding opportunities.
The inner context facilitators of the sustainability phase include continued efforts to
engage both internal and external stakeholders to the organization to facilitate and incorporate
feedback. To scale and replicate the MPTT to other hospital sites across the state, data will need
to be collected to determine whether the MPTT is a cost-effective alternative to hospitalization
and ER boarding and whether people seeking mental health care are able to access and utilize
care. Program evaluation of the MPTT every quarter will allow for ongoing monitoring to ensure
program effectiveness and meeting of the program mission as well as to maintaining program
fidelity while scaling and replicating the program to other sites.
Leadership Strategy
The leadership strategy suggested by Galbraith (2014) includes piloting the MPTT
program to organize the processes to scale the program in the future. The identified strengths,
weaknesses, opportunities, and threats (SWOT) analysis of the MPTT will assist in the
leadership strategy (Chopyak, 2013).
The MPTT strengths include its innovative mobility of the team to deliver equitable
mental health and crisis intervention to patients in the ER setting with the use of telepsychiatry
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 35
for the psychiatrist 24 hours a day as well as the case management offered after discharge for up
to 30 days. Cost savings is another strength of this program, as ER boarding prevents, on
average, 2.2 patients from being seen with hospitals losing more than $2,264 per patient being
boarded in the ER (Nicks & Manthey, 2012). In a discussion with a hospital administrator in San
Diego, the costs associated with ER boarding are challenging to estimate, and if a patient is held
in the ER for a prolonged period for psychiatric reasons, then this prevents other patients from
being treated (S. Carruthers, personal communication, February 22, 2019). Boarding represents
thousands of dollars in lost revenue. The MPTT will be providing patients a safe space to de-
escalate and receive crisis intervention outside of the ER setting thereby improving the flow in
the ER, which will offer financial incentives to hospitals and insurance companies.
The weaknesses of MPTT include the lack of a standard definition of ER boarding times,
as these vary across systems. Further, the team will need to establish collaborations with an
existing nonprofit organization to obtain grant funding. The population served during the pilot
will only be adults ages 18 to 64, which means children, adolescents, and adults over the age of
65 will not be treated during the one-year pilot. Lastly, the pilot is being implemented in an LPS
facility, which continues to prevent patients in non-LPS facilities from obtaining treatment.
The opportunities the MPTT presents include utilizing a multidisciplinary team of
providers who use their networks within the community to build a reputation as a trustworthy
organization and subsequent alliances (see Figure 3 for MPTT organizational structure). Ideally,
by piloting the MPTT first with adults, it can be further developed to broaden the scope of
services to include children and adolescents in the future. While the pilot is being conducted,
collaborations and work may be initiated to update the LPS Act for implementation in non-LPS-
designated hospitals. Future opportunities also include developing a freestanding PES or
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 36
Psychiatric Urgent Care program in conjunction with the County of San Diego’s current practice
of providing 24-hour walk-in and transfer services.
The threats to the innovation include replicability by other systems, lack of funding and
hospital collaborations, and lack of hospital space to run the MPTT program. Unfortunately, the
medical and psychiatric community may not support innovation, and stakeholders, including
consumers, may not support the efforts to change the mental health system.
Anticipating the success of the MPTT pilot, plans are to select additional hospital sites to
replicate the MPTT. Indeed, modifications might be made to the strategy based on the pilot
program evaluation. The ability to reproduce the model at other initial sites with positive
outcomes would support the expansion of the MPTT throughout the country. Success of the
MPTT pilot and the next level model development will help to close the health gap relative to
emergency psychiatric treatment, stabilization, and hospitalization.
Business Plans
The financial structure of the MPTT will follow a functional, single-line organization
format (Galbraith, Downey, & Kates, 2002). The MPTT will initially be formed as a Limited
Liability Company (LLC) and later partner with a local, established nonprofit organization with a
similar mission and vision. As an LLC, the author will contribute to the MPTT innovation,
retaining oversight and rights of program development. The MPTT will seek a partnership with
the UCSD Community Psychiatry Program, which is part of the UCSD School of Medicine.
Specifically, the director of psychotherapy and training has expressed interest in a partnership to
further develop the MPTT. The MPTT mission and vision align with that of the potential
partnership through UCSD. The processes in the leadership strategies include achieving mission
objectives and ensuring service quality. Partner collaborations aim to develop workflows,
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 37
processes for transfers and referrals, and working to derive data from the EHR and ensuring back
up protocols when the computer systems go down for maintenance. To gain support from local
organizations, hospitals, and politicians, the leadership plans to market the program and engage
social media to help educate people about the problem of ER boarding. The leadership structure
of rewards beyond wages includes providing annual raises each year with superior evaluations
and incentivizing working after hours, overnights, and weekends by providing differentials in
pay since the program will be operating 24 hours a day. To remain competitive, leadership on the
MPTT will need to evaluate opportunities for leadership promotions and provide monthly
recognitions highlighting top performance achievements (Galbraith, 2014).
A one-year budget is presented for the MPTT pilot program, which is designed as a 24-
hour response team based on the medical model. The format for budgeting is a cash format along
the same fiscal year as the hospital system from October 1 to September 30th. A line item budget
has been developed to describe the associated costs and funds available for the program within
the year (see Figure 4 for Program Budget in Appendices). The revenue projections include
private donations and in-kind contributions provided by the hospital; however, the bulk of
revenue will be derived from fee-for-service reimbursements. The MPTT will contract with
Medicaid, Medicare, as well as private insurers for the primary source of revenue. To consider
grant funding, the MPTT will need to develop a partnership with a nonprofit organization, which
will be discussed later in the proposal. With nearly 40% of ER visits in California associated
with behavioral health and substance use disorders (McConville, Danielson & Hsia, 2019), the
costs continue to rise for this particular population.
The personnel expenses (see Table 3 for personnel requirements) include the direct
service staff working 12-hour shifts, which maximizes and incentivizes staff. The RN’s starting
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 38
hourly wage will be $45.00 and require a minimum of three to five years of experience working
in an inpatient behavioral health setting with a Bachelor of Science degree in nursing. Candidates
should also be registered as an RN in California. The staffing required to start will be five full-
time RNs.
The SW will be a master’s level social worker (MSW) and licensed in California. The
staffing required will be three full-time Licensed Clinical Social Workers (LCSW) with a
starting hourly wage of $36.06 with a minimum of two years of experience working on an
inpatient mental health setting.
The MHW will have a minimum of a high school diploma with one year of experience in
direct patient care in a behavioral health care setting and must be enrolled in an accredited school
of nursing or social work or hold a Certificate in Nursing (CNA). The staffing required will be
five MHWs with a starting wage of $16.82 an hour.
Volunteer peer specialists and psychiatry residents will be unpaid positions.
The Utilization Review (UR) specialist will work full-time Monday through Friday, eight
hours a day. They will possess an RN or LCSW and be registered or licensed in the state of
California. The UR specialist will have a minimum of three years of experience working in a
behavioral health setting and require knowledge of medical necessity, obtaining authorizations
from insurance companies as well as the appeal processes. The UR specialist will be a salaried
position set at $85,000 annually.
Table 3
MPTT Personnel Requirements
Personnel Requirements Education Experience Starting
Wage
PRN Psychiatric Registered
Nurse in California
Bachelor of
Science degree in
Nursing (BSN)
Minimum of 3 years
working in an inpatient
behavioral health setting
$45.00/hr.
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 39
SW Licensed Clinical Social
Worker in California
Master Social
Work accredited
school of Social
Work (MSW)
Minimum 2 years
working on an inpatient
mental health setting.
$36.06/hr.
MHW Enrolled in accredited
school of Nursing or
Social Work or hold
Certificate in Nursing
(CNA).
High School
diploma or
equivalent.
1-year behavioral health
care setting
$16.82/hr.
UR
Specialist
RN or LCSW registered
or licensed in California.
Hold a BSN or
MSW
3 years working in a
behavioral health setting.
Require knowledge of
medical necessity,
obtaining authorizations
from insurance
companies as well as the
appeal processes.
$85,000
Annually
PRN
Director
Registered RN in
California
Master’s degree
in nursing or
higher
3 years performing a
management role in a
behavioral health setting.
$96,000
Annually
SW Director Licensed Clinical Social
Worker in California
Master Social
Work accredited
school of Social
Work (MSW) or
higher
3 years performing a
management role in a
behavioral health setting.
$96,000
Annually
Medical
Director
Board-certified
Psychiatrist
MD or DO 5 years providing
supervision and
leadership.
$150,000
Annually
Psychiatrist Board-certified
Psychiatrist
Doctor of
Medicine (MD) or
Doctor of
Osteopathic
Medicine (DO)
3-years evaluating,
diagnosing and treating
patients on an outpatient
or inpatient basis.
$120,000
Annually

The leadership team includes directors of nursing, social work, and medicine. The
director of nursing will hold a master’s degree in nursing with three years of experience in a
management role in a behavioral health setting. The director of nursing will be registered in
California and offered a salary of $96,000 annually. The director of social work will provide
leadership for the SW, MHW, and the volunteer peer specialists. The social work director will be
licensed in California with a salary of $96,000 annually. The medical director will be a Board-
certified psychiatrist who will oversee the per diem psychiatrists who will provide 24-hour
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 40
availability virtually. The medical director will be offered $150,000 annually. Three psychiatrists
who will provide 24-hour on-call coverage will be paid a contracted rate of $120,000 annually
plus reimbursement rates from fee-for-service reimbursements. Psychiatry residents may also be
rotated into the call schedule to be supervised by the medical director and psychiatrists, which
would be unpaid positions.
Additional associated expenses include the space donated in-kind by the hospital valued
at $125,000 and $90,000 for utilities annually. Anticipated space requirements include a
designated space of 2,500 square feet furnished with 15 reclining chairs and two tables for the
milieu area. The equipment and technology required include computers, virtual technology
(screens and cameras) as well as the purchase of an EHR software. Other electronic equipment
includes a Pyxis medication distribution system, a vitals machine, and 15 electronic tablets
preloaded for patients to take clinical self-reporting measurements, which will assist in managing
patient care. Training expenses, consultants for legal guidance, program evaluation, and auditing,
as well as office and marketing expenses are also factored into the budget. The annual budget
projected for the team to run for one year is $3,063,091 with a projected revenue of 4,280,000. It
is estimated that the MPTT will treat five patients per day with a reimbursement rate of $110 per
hour up to 20 hours. The cost savings to hospitals is projected to be over $4,131,800 per year
based on the estimated cost of $2,264 related to boarding a patient (Nicks & Manthey, 2012).
An unsolicited proposal has been developed (see Supplemental Material) to obtain
funding to begin implementation of the MPTT program. The presentation for the
BeHealth.Today will be recorded and uploaded to YouTube for potential County of San Diego
funders to review and consider for implementation.
Project Impact and Assessment Methods
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 41
The effectiveness of the MPTT program will be evaluated using the Crisis Reliability
Supporting Emergency Services (CRISES) framework (Balfour, Tanner, Jurica, Rhoads, &
Carson, 2016). The CRISES measurement domains (see Table 4 for MPTT CRISES measures)
address timely access to care, safety, accessibility to treatment, least restrictive level of care,
effective treatment, consumer and family-centered focus and partnerships which are highlighted
as the standards of crisis care (Balfour et al., 2016). The measurement of timeliness will require a
standard definition of when boarding begins. Notably, times vary across health systems and there
has been little guidance for consensus, except by the Joint Commission, which has recommended
that ER boarding should not exceed four hours (The Joint Commission, 2012). The suggested
measures for monitoring time in the ER include the Centers for Medicaid and Medicare Services
(CMS) standardized measures. The MPTT will collect all data systematically designed in the
EHR. The time will be documented at the time of the referral placed by the ER physician until
the MPTT arrives at the patient’s bedside based in minutes. The time of arrival to the MPTT unit
until the time of discharge will also be monitored, as patients will have up to 23 hours and 59
minutes on the unit.
Table 4

CRISES Measures
Timely Time in minutes from ER arrival to contact with the MPTT.
Time in minutes from the time the patient is admitted to the MPTT unit to the
time of discharge.
Safe Continuous patient monitoring of patient for duration of stay and
documentation of patient safety every 15 minutes.
“Number of self-directed violence with moderate or severe injury” and
“number of incidents of violence to other persons receiving care with
moderate or severe injury” (Balfour et al., 2016, p. 5).
Accessible Number of patients who are transferred to the MPTT unit.
Least Restrictive Number of voluntary patients admitted to MPTT.
Number of involuntary patients admitted to MPTT.
Discharge destination.
Number of patients discharged to the community.
Number of patients requiring inpatient level of care.
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 42
Note. Adapted from Balfour et al. (2016).
Safety will be monitored with 15-minute observations for the duration of the patient’s
stay. Accessibility will be measured by the number of patients admitted to the MPTT unit, as
there are 15 reclining chairs and thus it will be imperative to ensure patients are being seen and
treated expeditiously to ensure that access remains available. It is vital to ensure patients are in
the least restrictive level of care, so the number of patients admitted voluntarily and involuntarily
to the unit will be measured as well as the number of patients discharging to the community and
or transferring to an inpatient level of care. It will also be helpful to identify where they are
dispositioned. Measuring effectiveness of the intervention was documented by Balfour et al.
(2016) as recidivism or “a failure of the discharge plan” (p. 6). The MPTT will continue working
with patients following discharge for up to 30 days, and measurements of patients connecting to
their outpatient providers and other resources will be measured as an opportunity to prevent
recidivism. To ensure accuracy, the number of patients who reenter the ER within 30 days will
also be measured. The consumer/family-centered care includes measurements of the patient’s
satisfaction with the overall intervention and care received using patient satisfaction scores and
the number of patients who involve friends or family in their care. The SW will work with
patients and encouraged friends and family to be engaged in their care and disposition planning,
which will be documented in the EHR. Partnerships will be measured by the number of
collaborations made to ensure continuity of patient care measured by the number of contacts the
SW has with the patient after they discharge for up to 30 days to help patients navigate the
Effective Number of patients re-hospitalized within 30 days.
Consumer/Family-
Centered
Number of patients who have family/friends involved in their MPTT unit
stay.
Patient satisfaction.
Partnership Number of contacts the SW has with patient following discharge. The SW
will contact the patient at day three and day seven and will remain available
to the patient as needed for up to 30 days.
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 43
system. The outcomes derived from these measurements will provide the data required to scale
this program beyond the pilot program. It will also help to provide valuable insight into the best
ways to serve the population.
Program evaluation and feedback is essential, but so are clinical self-reporting measures.
Once patients are admitted onto the unit, they will be provided an electronic tablet (IPAD)
preloaded with self-reporting measures (see Table 5 for clinical self-report instruments) in both
English and Spanish. Patients will be encouraged to complete the scales to gather responses to
establish the most appropriate treatment plan based on reported symptoms. If patients are unable
to complete the scales electronically due to acuity, they may be verbally obtained by the MPTT
staff. Baseline data will be retrieved and include the following demographics: age, gender, race,
ethnicity, legal status (voluntary or involuntary), payer, housing status, and primary language.
The Patient Health Questionnaire (PHQ–9) will measure depression (Kroenke, Spitzer, &
Williams, 2001). The Generalized Anxiety Disorder 7-item (GAD–7) (Kroenke, Spitzer,
Williams, & Löwe, 2010) will assess anxiety. Suicidality will be measured using the Columbia
Suicide Severity Rating Scale (C-SSRS) (Posner et al., 2011). Alcohol and drug use will be
measured using the Alcohol Use Disorders Identification Test (AUDIT) (Saunders, Aasland, &
Babor, 1993) and the Drug Abuse Screen Test (DAST–10; Skinner, 1982). The team will be able
to extract data from these measures immediately to engage the patient in treatment and provide
feedback to the patient based on their self-report. Each of the measures has been determined to
be reliable and valid within the construct domain it is evaluating.
Table 5

Clinical Self-Report Instruments

1. Demographics Age, Gender, Race, Ethnicity, Payer, Legal status (voluntary,
involuntary), Housing status, Primary language
2. Mental Health
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 44
Depression Patient Health Questionnaire, PHQ-9
Anxiety Generalized Anxiety Disorder 7-item, GAD–7
3. Suicidality Columbia Suicide Severity Rating Scale, C-SSRS
4. Alcohol/Drug Use Alcohol Use Disorders Identification Test, AUDIT
Drug Abuse Screen Test, DAST–10
Note. PHQ–9, Kroenke et al., 2001; GAD–7, Kroenke et al., 2010; C-SSRS, Posner et al., 2011;
AUDIT, Saunders et al., 1993; DAST-10, Skinner, 1982.

Stakeholder Engagement Plans
The stakeholder engagement plan incorporates both formal and informal stakeholders
directly and indirectly impacted by the problem of ER boarding. The formal and informal
stakeholders associated with the problem are delineated in Figure 5 (see illustration of
stakeholders in Appendices). Each of the stakeholders is unique in their connection to the
problem, and it will be important to engage each of them to obtain information and feedback on
their perspectives about the issue as well as their proposed solutions. Informed community-based
decisions will be developed using the expertise and experiences of community stakeholders and
consumers. To engage the stakeholders, the MPTT will develop an integrated community-based
collaborative with invitations to each of the identified stakeholders. A focus group will be
utilized to engage the informal stakeholders, and an advisory board will be established for the
formal stakeholders. Both formal and informal stakeholders, including consumers, will be invited
to serve on the advisory board. Issues surrounding the implementation process will be addressed
as well as clarifying roles and responsibilities. A community collaborative will be developed
utilizing public, private, and nonprofit community agencies and organizations to establish MOUs
and performance agreements as a backup plan for patients who need continued treatment beyond
the 23 hours and 59 minutes allotted. It is anticipated that coordinating efforts with the crisis
houses, homeless shelters, and Homeless Outreach Team for patients that may require longer
stabilization and housing is critical for those patients who do not meet criteria for inpatient
psychiatric hospitalization. Likewise, MOUs will need to be developed with the local LPS
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 45
hospitals and insurance companies for psychiatric admissions beyond the 23 hours and 59
minutes to establish priorities, oversight, and development of the MPTT and its collaborations.
Connections and collaborations have already been developed with SDSU Social Policy
Institute and UCSD Community Psychiatry Program, which is connected to the UCSD School of
Medicine. Discussions about the opportunity to implement the MPTT program at Sharp Health
Care with the medical directors at Sharp Grossmont Behavioral Health and Sharp Mesa Vista
hospital have taken place. The author has also sought guidance regarding the implementation and
license requirements from the Clinical District Chief of the Department of Mental Health
Services in California. The interviews with key stakeholders have assisted in the development of
each of the components of this proposal.
Communication Strategy
The problem of ER boarding is systemic, and an understanding and awareness are
imperative at a higher level to enable change at all levels. The communications plan for the
implementation of the MPTT program (see Table 6 for communication plan) includes developing
opportunities to engage each of the stakeholders in the community to relay the message about the
implementation of the program and the need to improve the gap in the system of care. The
advisory board will communicate the message to the stakeholders and bring public attention to
the problem, especially focusing on how the problem is affecting people across the state and
nation.
The first strategy in the communication plan is to engage stakeholders by developing a
message on a dedicated website. Such a website would include information concerning
education, advocacy, and resources and an interactive storytelling mechanism to allow people
affected by ER boarding to share their stories. People could then elect to follow-up with the
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 46
media and local politicians to support them in their experiences to influence change. The stories
will then be produced into short-form videos in which patients and families can describe their
experiences to engage public awareness. People can type and tell their stories on the website, and
the advisory group will connect them to local leaders and policymakers to bring public attention
and oversight to this problem. Working with allies on legislation and timely access along with
insurance companies concerning fees is crucial for fixing this problem.
The second strategy would be to advertise on social media, including Facebook, Twitter,
Instagram, and YouTube, through unpaid and paid advertisements as an opportunity to spread
the news about this problem across the nation. Through these means of communication, the goal
is to educate and reach as many people as quickly as possible. On April 4, 2019, the author is
presenting at BeHealth.Today, which will be recorded and placed on YouTube for the County of
San Diego funders to review for potential future collaborations and implementation to improve
the mental health system in San Diego.
The third strategy is to communicate to the community through town hall meetings and
conference calls highlighting the problem, proposed solution, and discussion of next steps with
opportunities to ask questions and engage in the resolution process. The invitation would be open
to all informal stakeholders and community advocacy programs.
Table 6
Communication Plan Strategy
Strategy 1: Website • Statistics, Facts, Information
• Community mental health resources, where to go for help
• Messaging board
• Link to tell personal stories
• Direct links to elected officials
• Notice of meetings
• Opportunity to donate/contribute
Strategy 2: Social Media • Advertising on Facebook, YouTube, Instagram, Twitter
• Education and endorsements
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 47
• Paid and unpaid advertising
• Presenting at BeHealth.Today
• Increased visibility of the MPTT program

Strategy 3: Town Halls • Advisory board to hold local informational sessions
• Conference calls
• Developing community solutions
Strategy 4: Meetings • Meetings held in person
• Virtual meetings
• Meetings with hospital administration and staff
Strategy 5: Electronic
Communication
• Weekly emails to communicate to stakeholders
• Development of dashboard
• Include dashboard on website
• Survey administration

The fourth strategy is virtual and in-person meetings with hospital administrators and
staff that can be recorded for viewing if people are unable to attend. Meetings would be held
bimonthly to address the concerns of the teams impacted at the hospital level. Three months
before implementation, biweekly meetings for updates concerning processes and implementation
will be planned. The MPTT will also be meeting weekly within the same period before going
live.
The fifth strategy for communicating with the stakeholders includes weekly emails with
updates and the development of a dashboard to keep everyone on board with the
accomplishments to date. The dashboard would be available on the website. The final strategy is
to conduct surveys throughout the process to engage stakeholders and obtain feedback.
Ethical Considerations
The development of the MPTT pilot program in partnership with UCSD will work to
close the health gap in the mental health system in San Diego. The comprehensive plan detailed
within this capstone proposal provides a pathway for individuals accessing the ER for behavioral
health treatment. After careful consideration, it was determined that this stage of the proposed
project does not meet the threshold for submittal to an institutional review board (IRB) because it
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 48
is not an experiment and does not have a control group. The MPTT proposal will need to follow
the basic standards set forth by the National Association of Social Work (NASW) Code of Ethics
(NASW, 2019). Negative consequences that could arise include privacy and confidentiality
breaches regarding EHR and the use of virtual technology. The MPTT will be an integrated team
within a medical hospital setting; thus, it will be essential to sensitize psychiatric records and
ensure that all use of technology is appropriately secured.
Further risks include treating patients who are at high risk due to the risk of danger to self
and others and not being able to care for themselves. Suicide risk increases after a patient has
been hospitalized due to “re-exposure to community stressors, non-adherence, non-engagement
with outpatient providers, relapse, and the return of insight regarding the consequences of the
mental illness” (Meehan et al., 2006 as cited in Salvatore, 2012, p. 48). It was further highlighted
that the support of the hospital setting is no longer available, which also increases the risk of
suicide (Salvatore, 2012). To mitigate the risk, the MPTT will provide ongoing case management
care and access to the psychiatrist for up to 30 days to continue support until patients can connect
with their outpatient providers, but this support may be extended as needed. Another mitigating
factor includes encouraging family, friends, and peers to be engaged in the treatment process and
discharge plans to develop plans for restricting access to means and observation after leaving the
MPTT program.
The legal risks associated with treating this population include the LPS Act, which does
not state the plan of treating patients in non-LPS-designated hospitals. Legally, the MPTT will
have 23 hours and 59 minutes to treat patients. Contingency plans will be required to be in place
for patients who need longer stabilization but do not meet criteria for inpatient hospitalization.
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 49
The financial risks include developing partnerships to secure grant funding to start-up
MPTT. Donations and grants come with restrictions and stipulations on how the money is to be
used, so it will need to be closely monitored. It is projected that fee-for-service reimbursements
will be self-sustaining, but the time between filing and receiving reimbursements can be lengthy.
Conclusions, Actions and Implications
The next steps to successfully implement the MPTT include developing a partnership
with UCSD to be eligible for consideration for grant funding. Other identified potential nonprofit
partnerships that may be pursued include SDSU Social Policy Institute.
Once a hospital is identified for implementation, the MPTT plans to work with the
hospital administration to establish baseline data on LOS for patients with behavioral health
conditions. The MPTT will also conduct focus groups within the community surrounding the
hospital to gain an accurate assessment of the specific needs for the population to identify the
most critical collaborations with community partners to address the needs of the population. An
advisory board will be developed with key stakeholders to help guide the implementation of the
MPTT. The advisory committee will organize meetings with ER physicians and the board of
directors of the hospital and meet with local and state leaders to educate and provide new
perspectives on mental health care as an essential equal to medical care.
The limitations of the proposed MPTT innovation include incorporating a mental health
program into a general medical setting, which is contrary to current practices. With the
implementation of the innovation for adults over the age of 18 entering the ER, there remains a
significant population of children and adolescents who will stay in the ER waiting for treatment.
The MPTT will require adult patients to be medically stabilized by the ER physician, so they will
not be able to obtain mental health treatment until they are stabilized medically. Another
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 50
limitation is that the program cannot be funded by grants until a partnership is established with a
nonprofit status. Identification of a partnership and funding will need to be secured before
implementation. Limitations to the program design and implementation include patients
readmitting to the ER despite being provided case management services for up to 30 days.
Patients may not want to seek out mental health treatment for fear of stigma. Stigma also
prevents people with severe mental illness from obtaining medical treatment (Ostrow,
Manderscheid, & Mojtabai, 2014), which may stop some patients with medical problems from
being treated by the MPTT because they are more difficult to stabilize medically.
The MPTT is an innovative program that will provide immediate treatment to people in
the ER in a behavioral health crisis. By implementing the MPTT, patients will have access to a
specialized mental health treatment team, which would create equity in available emergent care.
Research indicates there is a significant cost saving when using a crisis model compared with
inpatient hospitalization (Bennett & Diaz, 2013). Specifically, it is hypothesized that there will
be a cost savings of over four million dollars annually to hospitals that implement the MPTT as a
result of transferring patients out of the ER and into a more appropriate setting for the crisis to
resolve.
The collaborations with stakeholders and the implementation of the communication plan
will generate increased awareness of ER boarding and the current gaps in the mental health
system. We are still utilizing the same mental health options since the 1960s. It is time to change
the trajectory of care and implement treatment options at the source of the problem: the ER. The
MPTT aspires to improve the health and well-being of patients and offer dignity and respect at
the least restrictive level of care, ultimately eliminating stigma, creating equitable care for people
seeking mental health treatment, and closing the health gap.
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 51
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CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 65
Appendices

Figure 1. MPTT Comparative Analysis

CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 66

ER staff call the MPTT intake line and the team is deployed to the ER.
Patient is evaluated by the ER physician and medically stabilized. The ER
physician refers patient to the MPTT due to mental health condition identified.
Patient arrives to the emergency room (ER) in a behavioral health crisis and is
triaged by the ER RN.
MPTT Psychiatric Registered Nurse (PRN), Mental Health Worker (MHW) and
Social Worker (SW) arrive to ER within 30 minutes.
MPTT intake staff calls the Psychiatrist (MD) to discuss clinical and admission
orders for patient.
Verbal handoff and documentation are provided from the ER RN to the PRN.
The patient is transferred to the MPTT unit out of the ER.
Patient is evaluated by PRN for initial nursing assessment, PRN begins
discharge planning discussion with patient. Patient is provided IPAD to complete
clinical self-reporting measures. PRN and MHW complete patient safety check.
Safety checks continue every 15 minutes.
Patient evaluated virtually by MD within four hours for history and physical
evaluation and medication consultation. MD discusses discharge plans.
Biopsychosocial evaluation conducted by SW and connections made to engage
family, peers. Discharge planning discussion continues and Conjoint meeting
with patient’s support system initiated in person or virtually.
The MHW works with patient on the Wellness Recovery Action Plan (WRAP) with
patient (Copeland, 2002) either individually or in group.
The SW works with patient individually on the WRAP developing safety & coping
plan. SW solidifies discharge plans with patient. Individual therapy provided.
PRN administers medication as needed. Patient encouraged to participate in
group therapy available working on coping skills, safety planning and WRAP.
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 67
Figure 2. MPTT Workflow Continued

PRN conducts 12-hour nursing assessment with patient and preparation for
discharge continues. SW, PRN & MHW and MD consult. Final disposition
determined.

Patient determined to be safe
to discharge to lower level of
care.
Patient is requiring longer
stabilization and is meeting
criteria for psychiatric admission.
Patient referred to MD for
final evaluation and
discharge is finalized.
SW meets with patient to
schedule follow-up
appointments, provide
resources, and confirm
discharge plans and
preferences for transportation
home or other lower level of
care. Connection with
support system encouraged.
Patient is discharged within
23 hours 59 minutes.
SW provides ongoing support by
telephone or virtually contacting patient
at day three and seven to ensure
successful discharge planning and
connections to community providers.
SW remains available up to 30 days as
needed.
PRN calls for bed availability in
community and begins referral
process.
MPTT continue to work with
patient providing ongoing support
and safety monitoring.
PRN secures bed for patient at a
hospital and arranges ambulance
transportation for transfer.
MD orders transfer for inpatient
level of care.
Patient is discharged and
transferred to inpatient facility
within 23 hours and 59 minutes.
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 68

Figure 3. MPTT Organizational Structure

Psychiatric Registered Nurse
Director of Nursing
Social Worker
Mental Health Worker Peer Specialists
Director of Social Work
UR Specialist
Psychiatry Residents
Psychiatrist
Medical Director
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 69

Figure 4. MPTT Program Budget
ITEM DESCRIPTION COST
Revenue
Third Party Payments
Avg. 5 people per day at $110/ x 20
hours x 365 4,015,000 $
Fund Raising / Donations 50,000 $
In Kind Contributions Rent @ $125,000 & Utilities @ $90,000 215,000 $
Subtotal 4,280,000 $
Expenses
Salaries and Wages
Program Director, RN 1 FTE @ $8000/month/12 months 96,000 $
Program Director, LCSW 1 F.T.E.@$8000/month/12 months 96,000 $
Psychiatric Social Worker, LCSW 2.7 F.T.E @$6250/month/12 months 225,014 $
Medical Director, MD 1 F.T.E @$10,833/month/12 months 150,000 $
Registered Nurse, RN 4.5 F.T.E @$7020/month/12 months 421,200 $
Psychiatrists 3 @ contracted rate/ 24 hour on call 360,000 $
UR specialist RN 1 F.T.E @$7083/month/12 months 85,000 $
Mental Health Worker 4.5 F.T.E @$2624/month/12 months 157,435 $
Salaries Subtotal $1,590,649
Fringe Benefits % Total
Salaries
FICA 7.65% 7.65% Social Security: 7.65% of Total S. $121,685
Workers Compensation 3% 3.00% Workers Compensation: 3% of Total S. $47,719
State Unemployment Ins. 2.0% 2.00% State Unemployment: 2% of Total S. $31,813
Medical Insurance 6% 6.00% Medical Benefits: 6% of Total S. $95,439
Pension 5% 5.00% Pension Benefit: 5% of Total S. $79,532
Fringe Benefit Subtotal 23.65% $376,188
Total Salaries and Wages 1,966,837 $
Consultant and Subcontract
Consultants Legal //Program Evaluation 100,000 $
Total Consultant and Subcontract 100,000 $
Services and Supplies
Training Expenses EBP Training/Certif: 20 staff at $2771 ea. 55,420 $
Office Supplies Office supplies / fundraising 5,000 $
Telephone Install, Office, Cell and Internet 6,300 $
Community Outreach and Engagement Outreach Materials, Postage, Marketing 5,000 $
Total Services and Supplies 71,720 $
Other
Utilities In-kind 90,000 $
Facility Expense Rent in-kind 125,000 $
2,500 sq. ft x 12 months.
Equipment & Technology
Computers, Virtual capability,
Cameras, Furniture, Elec health record,
vitals monitoring, Pyxis medstation,
15 Electronic tablets 250,000 $
General Liability/Malpractice Insurance Liability insurance 60,000 $
Total Other 525,000 $
Total Direct Expenses 2,663,557 $
Total Indirect Costs 15% of Total Direct Costs 399,534 $
Total Project Cost Total Direct plus Total Indirect 3,063,091 $
MOBILE PSYCHIATRIC TREATMENT TEAM
CLOSING THE HEALTH GAP: THE DEVELOPMENT OF A MPTT 70

Figure 5. Illustration of Stakeholders.

Abstract (if available)

Abstract The proposed innovation addressing the Grand Challenge of Social Work to Close the Health Gap brings a mobile interdisciplinary team of providers including a psychiatrist available virtually 24 hours a day, an onsite Psychiatric Registered Nurse, Social Worker, and Mental Health Worker to provide immediate crisis intervention to patients being held in the ER. The Mobile Psychiatric Treatment Team (MPTT) will bring the inpatient behavioral health team to the patients in the ER rather than sending the patient to the hospital for acute mental health care. The MPTT will have 23 hours and 59 minutes to stabilize the acute crisis or continue the plan for transfer to an inpatient hospital ensuring treatment at the least restrictive level of care. By collaborating with hospitals to develop a designated space away from the ER to allow patients the specialized care in a calm and healing environment. The MPTT will continue to provide short term case management ensuring continuity of care for up to 30 days to bridge the gap until patients establish connections with their outpatient providers. The outcome from this intervention will decrease ER boarding of patients with mental health conditions and de-escalate the crisis while reducing the need for inpatient psychiatric hospitalization, ultimately improving access to mental health care while providing cost savings to hospitals, insurance companies, and patients.

Linked assets

University of Southern California Dissertations and Theses

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Asset Metadata

Creator Krekler, Lisa (author)

Core Title Closing the health gap: the development of a mobile psychiatric treatment team

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 05/09/2019

Defense Date 04/11/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag alternative treatment options,crisis intervention,emergency room boarding,Mental Health,OAI-PMH Harvest,psychiatric treatment in the emergency room

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Lee, Nani (committee chair), Manderscheid, Ron (committee chair), Singh, Melissa (committee chair)

Creator Email krekler@usc.edu,Lkrekler@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-156772

Unique identifier UC11660524

Identifier etd-KreklerLis-7430.pdf (filename),usctheses-c89-156772 (legacy record id)

Legacy Identifier etd-KreklerLis-7430.pdf

Dmrecord 156772

Document Type Capstone project

Format application/pdf (imt)

Rights Krekler, Lisa

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA