Emergency department visits continue to rise: The Centers for Disease Control and Prevention estimates that between 2006 and 2014, there was a nearly 15 percent increase in the nation’s use of the emergency room (ER), despite two decades of American health-care providers working to keep patients out of the ER by expanding primary-care access. In addition, a 2017 report by the Agency for Healthcare Research and Qualityopens in new window found that the number of ER visits related to mental health and substance-use issues increased more than 44 percent during that same time period, with suicidal ideation visits growing by nearly 415 percent.
In Detroit, the Henry Ford Hospital ER sees a daily influx of gunshot and assault victims, as well as patients with substance use and serious mental health issues. It’s the third-busiest emergency department in the state, with more than 100,000 visitors annually. As the first psychologist to be integrated into the hospital’s ER, Jennifer Peltzer-Jones, PsyD, RN, is working to reduce those numbers and the amount of time patients—especially those with behavioral health needs—spend there.
Peltzer-Jones spends her days treating patients with a wide range of conditions: anxiety-induced panic attacks, substance use disorders, personality disorders, schizophrenia-induced psychosis, suicidal thoughts or attempts, and more. In addition to improving admission procedures so that patients get the care they need more quickly, she works directly with patients—particularly repeat visitors and patients who have experienced trauma—to explore the reasons behind their frequent trips to the ER.
“There are patients who traditionally an ER doc might see and say, ‘OK, follow up with your primary-care doc’ and send them on their way,” says Peltzer-Jones. “But when you have a strong mental health system embedded within the ER it’s more like, ‘Hold on, these are health behavior problems. Let’s have our psychologist come see you.”
Putting patient needs first
Peltzer-Jones’s expertise in both nursing and psychology has helped to greatly improve the department’s work flow, says Gerard Martin, MD, a former chair of Henry Ford’s emergency department who continues to work as a physician on the unit.
Peltzer-Jones works closely with the ER physicians and nurses to assess a patient’s condition and determine the level of care he or she needs—whether that is admission to an inpatient psychiatric unit, a transfer to another community facility or preparation for discharge.
“Having Dr. Peltzer-Jones on the team takes a lot of the work off me and the medical residents, and it’s done by someone who is much more efficient, effective and knowledgeable about these issues than I am,” says Martin, who created Peltzer-Jones’s position in the ER in 2008. “We work together, but she does all the legwork.”
One major subgroup of patients under Peltzer-Jones’s care are the “super-frequent users”—those who visit the ER at least 10 times a year and are now referred to her upon their arrival. For each, Peltzer-Jones and her team develop an individual care plan that spells out the patient’s medical services, social services, and mental health referrals and strategies.
These care plans are an outgrowth of the hospital’s Community Resources for Emergency Department Overuse (CREDO) program, which was developed to manage the increasing number of frequent ER users. The approach appears to work. In a study the team conducted examining the medical records of 255 super-frequent users who sought care at Henry Ford’s ER from 2004 to 2013, they found that CREDO significantly reduced their ER visits. Before CREDO was initiated, the super-frequent users sought care in the ER an average of 32.4 times a year. After the hospital implemented the program, super-frequent-user visits by patients seeking pain-relief narcotics dropped to 13.8 visits a year. Meanwhile, visits by other super-frequent patients—those not seeking narcotics—dropped to 11.6 visits a year.
For Peltzer-Jones, those numbers illustrate how health psychologists’ interventions on health-care teams can dramatically improve patient outcomes. “It means sitting down with patients and figuring out what the underlying biopsychosocial factors might be and helping them address those.”
And those interventions go beyond the health-care facility. Peltzer-Jones also works to ensure these patients have stable housing, Martin says, which can be a critical part of care for those with mental health issues.
“Often, if you can just get these patients into good housing, you’ll decrease their use of the system and they will do much better on their own,” Martin says. “Dr. Peltzer-Jones provides these patients with some consistency and continuity of care by taking the time to get to know them and get a feel for what their circumstances are—what would work for them and what wouldn’t,” he says.
Advocating for safety
Improving workplace safety is another focus for Peltzer-Jones. According to a 2015 report by the U.S. Occupational Safety and Health Administration, health-care workers nationwide are four times more likely to be victims of serious workplace violence than are people in private industry as a whole. Of the workplace violence against health-care workers, 80 percent came from patients. And those are just the serious incidents, the ones that caused injuries severe enough to require time off.
To help tackle the issue of employee safety, Peltzer-Jones was appointed to a committee in charge of improving workplace violence for Henry Ford Health System’s more than 30,000 workers. As part of her role, she’s working to develop a notification system that operates through Henry Ford’s electronic health- record system to flag patients who have been violent toward staff.
“Not only does this help alert our employees as to how this patient has behaved in the past and allow them to work together to avoid further incidents of violence with that patient, it allows us to track a patient’s history of violence to determine if additional services might be needed for this individual,” she says.
Peltzer-Jones has also tackled patient safety needs on the administrative level, working to change longtime hospital, health system, and county- and statewide policies related to mental health patients, says Seth Krupp, MD, medical director in Henry Ford Health System’s department of emergency medicine. For instance, Peltzer-Jones has led the development of Henry Ford Hospital’s policy around managing agitated patients in its medical units, including the appropriate use of sedation and restraints on patients with mental health issues who visit the ER.
Perhaps Peltzer-Jones’s biggest accomplishment in this area, says Krupp, has been reducing the unnecessary lab work that psychiatric patients had been required to undergo. Historically, hospital transfers to mental health facilities or partial hospitalization programs required all patients to get a complete set of lab work to test for such factors as drugs in their systems, whether they were pregnant, and their blood counts and electrolyte levels. Recognizing how distressing, time-consuming and often unnecessary these tests are for patients with a mental illness, Peltzer-Jones worked with physicians and community stakeholders to get many local facilities to accept a standard physician evaluation that verifies a psychiatric patient’s medical clearance.
It’s saving the ER money and improving patient comfort, says Krupp. The new method is now under review for acceptance throughout Michigan.
“Dr. Peltzer-Jones is the strongest advocate we have for our psychiatric patients,” Krupp says. “Her ownership and focus on the care of these patients in the emergency department is very strong. She really challenges us as physicians and some of our ingrained ways of thinking.”
The Monitor’s “Adventures in Integrated Care” series explores the work psychologists are doing as members of interdisciplinary teams. If you have a story to share, contact editor Sara Martin at smartin@apa.org.
