The Modesto Bee
By Ken Carlson
MODESTO, Calif. -- Paramedic Dennis Flannery is one of eight medics in a Stanislaus County pilot program that is ensuring people in a mental health crisis are taken promptly to the care they need.
Our goal is to help people in a behavioral health crisis to avoid extensive emergency room stays, if the (mental health) crisis is their only emergency at that time,” Flannery said.
The community paramedicine program -- a first in California -- was launched in fall 2015 because too many patients in psychiatric crises are delayed in hospital emergency departments. In the past four years, paramedics who received special training assessed 1,473 patients in the field and took 429 of them directly to a mental health crisis center.
The new approach has relieved some pressure on hospital emergency departments, where mentally distressed people are normally delivered for an initial medical screening. Santa Clara and Fresno counties are also testing the program, which shows promise for reducing the number of psychiatric patients in crowded hospital ERs that can’t give them needed treatment.
At hospitals in Modesto and other cities in California, mental health patients are stuck in emergency departments for hours or days waiting for a medical exam or transfer to a mental health crisis center.
By using community paramedics to screen them in the field, many local patients are bypassing the ER and getting prompt care at the county’s psychiatric health facility (PHF) or a crisis unit in Ceres. In addition, police officers spend less time handling 911 calls for psychiatric emergencies and return to law enforcement duties.
Our hospitals are bursting at the seams, and we have too many people on our streets who are suffering from mental illness,” said Dr. Kevin Mackey, medical director for Mountain Valley Emergency Medical Services Agency, which oversees the Stanislaus program.
“Instead of languishing in a hospital, they get the best care from a trained psychiatric professional as fast as possible,” Mackey said.
Mackey said the program thus far has put a small dent in a major problem. An increase in licensed psychiatric beds is necessary for getting a larger number of suicidal or psychotic patients to a crisis center more quickly.
The program is designed to address a widespread problem of harboring mental health patients in hospital emergency departments across California.
Patients in a suspected psychiatric crisis are taken to medical centers because of a federal law called the Emergency Medical Treatment and Labor Act. Patients have rights under EMTALA to be examined for any medical emergency that needs attention.
Many patients with severe symptoms wait in ER beds for hours, and even after they are medically cleared, some remain for several days until a bed is available in a psychiatric hospital. In the meantime, they are not given effective mental health care.
The community paramedicine program is bypassing the ER and taking eligible patients to a lower level county facility where they can cope with their symptoms.
We are already seeing the benefits,” said Ruben Imperial, interim director of county Behavioral Health and Recovery Services. “If it does continue, it will have a significant impact on how we can respond to our local mental health crisis.”
Hospital “boarding” of mental health patients largely stems from almost a 30 percent decrease in capacity at psychiatric hospitals in California over the last 25 years. Patients with psychiatric symptoms worsen the gridlock in hospital emergency departments, which saw almost a 45 percent increase in overall patient visits from 2006 to 2016, according to the California HealthCare Foundation.
Paramedics with American Medical Response in Modesto received 170 additional hours of training for the program beyond what’s standard, so they can effectively screen mental health patients, Mackey said. In addition to classroom training, the paramedics went through emergency room rotations and trained with the county’s mental health crisis intervention team.
When Flannery is dispatched to a scene for a mental health emergency, he often confirms the initial assessment of the paramedic in the field.
The community paramedics also assist police in Modesto and Turlock when they deal with mentally distressed individuals. Through the pilot program, the person can be taken by ambulance to the appropriate facility and the officers soon return to law enforcement work.
Otherwise, an officer placing a person on a “5150" hold transports the person in a patrol car to the hospital and then waits for emergency room staff to accept the patient.
When it comes to 5150 calls, it takes a lot of the officers’ time and it takes them out of the field,” said Modesto Police Chief Galen Carroll, who wants to see the program continue. “If we can get the officers back (on patrol) then it helps us more.”
Paul Harper, an AMR supervisor, said a person with severe mental health symptoms is checked in the field for any wounds or medical complaints. The paramedics also make sure the person is not drunk or high on drugs or taking medication that caused their deteriorated condition.
Those who are uninsured or on Medi-Cal are eligible for admission to the 16-bed county PHF.
Mackey, who co-authored a peer-reviewed paper on the first 1,000 patients, said the paramedics never overlooked a person with a medical condition that required attention in the hospital. Only 12 patients delivered to the county PHF needed to backtrack to the emergency department.
Of the 12 patients, some had insurance issues and one needed a CPAP machine for sleep. Four of those taken to the ER were returned to the county mental health facility.
An independent evaluation of the three county programs this year, by the Healthforce Center at University of California San Francisco, found that 98 percent of patients taken to mental health crisis centers received safe and effective treatment and “no patients experienced adverse outcomes.”
Two percent, or 47 patients, were moved from a mental health center to an emergency department within six hours of admission. But none of those patients had a life-threatening condition, the report said. Four of those transferred to the ER were placed in inpatient beds for medical care.
The UCSF report estimated the pilot programs in three counties resulted in $2.2 million in cost savings by reducing ER visits and ambulance transports from hospitals to psychiatric facilities.
Hundreds of people assessed in the field were not sent to a mental health crisis center. They had medical needs or their vital signs were a concern. Some were intoxicated, agitated, violent or older than 65, the UCSF report said.
Residents in Stanislaus County placed on “5150" holds, because they’re considered a threat to themselves or others, are given the choice of the county crisis center or the emergency department.
Mackey said the Stanislaus program dealt with almost 490 adults who were candidates for direct admission to Doctors Behavioral Health Center on Claus Road, but access was restricted by space limitations and internal issues. Those patients were delivered to a hospital emergency department because Doctors Medical Center has not provided staff at DBHC for medical screening exams, Mackey said.
The 67-bed psychiatric hospital is under the license of Doctors Medical Center, which requires a visit to the emergency department before patients are sent to DBHC to be stabilized.
Medical screenings at DBHC could be done by a physician assistant, Mackey noted. Between those 490 patients and the 429 diverted from ERs, Mackey said, more than 900 patients could have been kept out of emergency departments since 2015 if there was better access to the Claus Road center.
If we can take them out of the emergency departments, then ERs can do what they do best and allow psychiatric specialists to focus on what they do best, which is taking care of acute mental illness,” Mackey added.
Dr. Robert Donovan, an emergency room physician at Doctors Medical Center, praised the pilot program and said the paramedics were trained well in deciding which patients are sent to psychiatric care and which ones need the emergency room.
He said the efforts, however, are hamstrung by EMTALA requirements, which is why the emergency room remains a destination for patients who need care at DBHC. Donovan suggested a mid-level health provider be considered for the psychiatric hospital.
“That decision has to be made at the hospital level,” he said. In a statement, Doctors Medical Center said DBHC is governed by federal rules that require screening of patients in the emergency room. Although the pilot program operates under a state waiver, a federal agency has not issued an exception to EMTALA requirements, the statement said.
Emergency service agencies in California are testing 15 community paramedicine programs using alternative destinations for delivering health care, thanks to waivers granted by the Office of Statewide Health Planning and Development. Trial programs in other counties involve urgent care, tuberculosis therapy and sobering centers for intoxicated adults.
OSHPD has reauthorized the waivers every November, though it’s not meant as a permanent loophole in the law. The California Nurses Association has opposed legislation to authorize the community paramedicine programs, saying that ambulance companies can’t provide high quality health services.
In the coming legislative season, proponents expect to see a third attempt to pass legislation supporting the paramedicine programs. A bill failed to reach Gov. Gavin Newsom’s desk this year and former Gov. Jerry Brown vetoed legislation in 2018.
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