Recently, Dr. Victor Hong, medical director of psychiatric emergency services (PES) at Michigan Medicine, contacted the millage-funded CARES team at Washtenaw County Community Mental Health. He had been notified that an individual in the community showed signs of being suicidal.
“The individual wasn't home [when the CARES mobile crisis team arrived],” Dr. Hong continues. “Typically, I would expect an agency to say, ‘Hey, we tried.’ But CARES did not do that. They stayed for 30 minutes and tried to use other methods to locate the individual.”
Once the person of concern came home, the team was able to complete a crisis evaluation on the spot, without a visit to the hospital.
“That was one example in which we, number one, made sure somebody was safe, and number two, they didn't end up needing to come to the emergency department.”
Dr. Hong and many others believe the work of the millage-funded CARES team has “made a substantial dent” in mental health hospitalizations in Washtenaw County, which are decreasing overall.
Avoiding hospitalization is preferable for many patients
Millage programs are working to reduce mental health hospitalizations both by reducing the number of emergency department psychiatric patients who are admitted to the hospital and by reducing the number of people who need to visit the emergency department for psychiatric services.
While hospitalization does provide the most appropriate care for some mental health patients, it can be harmful for others.
“Whether they have social anxiety or post-traumatic stress disorder, or don't do well in groups or have some history of incarceration, there are a lot of reasons why somebody might not want to be locked in a facility,” says Dr. Hong.
Even going to the emergency department can be traumatic for some patients] especially if they're forced to be there,” Dr. Hong continues. “People may come out at even more risk than when they came in.”
The underlying issue is that mental health care often acts as a “binary system”: either infrequent outpatient care or an isolated psychiatric unit. “There's a huge gap between going to see your therapist every few weeks and being locked in a hospital,” says Dr. Hong.
“A lot of people are in locked facilities, not because they absolutely need to be, but because there's a lack of intermediate options, other than some partial hospital programs” he adds. In addition to not serving those patients well, that also takes up limited psychiatric beds for the people who truly need them.
The millage-funded CARES team is one way to begin filling these gaps
The millage-funded CARES team works to prevent hospitalizations and crises by using case management and wraparound support.
Before millage funding, Washtenaw County Community Mental Health (WCCMH) could only serve people with Medicaid coverage and severe diagnoses. Other residents often had to wait months to access care, and even then, they usually did not have access to case management and peer support specialists, other important supports the CARES team provides.
But for the last two years, the CARES team has been able to serve all county residents, including people with Medicare, private insurance, no insurance, and those who aren’t yet U.S. citizens but reside in Washtenaw County.
“Reducing the need for admission is number one, which is why the CARES team is so crucial,” says Dr. Hong.
“A lot of people come to the hospital because they don't have adequate outpatient care," says Dr. Hong. "Wait lists can be three to six months to find a psychiatrist, and if you're in a mental health crisis, you can't wait that long. So what do you do? You go to the emergency department." And from the emergency department, there's a chance that you will be admitted for a longer hospital stay.
When patients do come to the emergency department, the CARES team can connect a patient with a therapist and case management, reducing unnecessary hospitalizations.
“We divert that person from getting hospitalized, which is really disruptive and a last resort,” says Shannon Ellis, CARES supervisor. “Every day as I look at our records from the night before, I see multiple referrals to the CARES program from people who have been to the ER. We get contacted all the time by hospitals or community partners.”
And if hospitalization is the right choice, CARES can provide the necessary aftercare, minimizing the need for re-hospitalization.“[CARES] is a great hospital follow up choice…because we can get people to a psychiatrist for follow up care quickly,” says Ellis.
Another new millage-funded resource is the 750 Crisis Center, a psychiatric observation center open 24 hours a day, 7 days a week. It offers an intermediate level of care between outpatient services and hospitalization, as well as additional services like peer support groups.
“A lot of people might be better served in a specialized mental health crisis setting, as opposed to a general emergency department,” says Dr. Hong.
Providing face-to-face crisis care during a pandemic
During the COVID-19 pandemic, CARES has provided face-to-face care that may not have otherwise been available.
“The other main benefit from the millage funds is that they’ve been able to expand their mobile crisis team,” says Dr. Hong. “Twenty-four-seven, 365, they can do a face-to-face evaluation. And that’s crucial to determine whether somebody needs to come into the emergency department.”
This service benefits therapists and psychiatrists, most of whom have switched to virtual care, which limits how they can respond to a patient in crisis. Without the CARES in-person evaluation, the emergency department is often the default.
“[CARES is] able to provide a robust infrastructure, so more of these individuals in crisis can be evaluated in person, in the moment,” says Dr. Hong.
“Many [therapists] rely on the crisis team now more than ever before,” says Dr. Hong. “From my conversations with the local schools and the University of Michigan, they are all grateful for the services that CARES provides.”
The data shows mental health hospitalizations are decreasing
Data collected by Washtenaw County Community Mental Health (WCCMH) show mental health hospitalizations are decreasing in Washtenaw County since the CARES program was implemented. While the data cannot prove that CARES is the cause, the metrics are worth reviewing.
The data focused on individuals who do not qualify for traditional WCCMH services--individuals with mild- to moderate mental health needs or those with severe needs who do not have Medicaid coverage--which is the group that the millage-funded CARES team aims to serve.
The number of CARES-qualified individuals in the dataset has increased due to accessibility and awareness improvements, especially in rural areas. But while the number of individuals goes up, the rate of psychiatric hospital admissions - calculated as the number of hospitalizations over the number of individuals who received an emergency service from CARES - is going down.
The average hospitalization rate was 6 percent from August 2017 to June 2019, when the millage expanded the CARES team. From July 2019 to February 2021, the average hospitalization rate was 3 percent. This difference remains striking even when excluding April and May 2020, which had exceptionally low psychiatric hospitalization numbers due to COVID.
Among the CARES-qualified group, those who choose to engage with CARES - individuals who received an intake and at least two visits from CARES staff - have a much lower rate of hospitalization than CARES-qualified individuals who do not engage with CARES.
This data implies that the CARES program is contributing to the lower hospitalization rate.
In addition, hospital recidivism - defined as another hospitalization within a year - is also much lower for CARES-qualified individuals who engaged with the CARES team.
“Our hospitalizations were exploding just two years ago,” says Michael Harding, deputy director of WCCMH, while responding to the analysis developed by Laura Higle, performance improvement division manager, and James Dalrymple, management analyst.
“Since the implementation [of millage funding for CARES], this data shows that hospitalizations are down, and that’s good for quality of care, it’s good for financing, and it allows us to fund preventative services instead of reacting to crises.”
Goals for the future of CARES
Going forward, WCCMH hopes to add more services and staff to the CARES team. One goal is to provide short term therapy with WCCMH staff, since currently patients still have to wait to be seen by community therapy providers.
The CARES team only provides temporary care in order to serve as many people as possible. They work with patients until they can connect patients to permanent community-based care providers, but in some cases that can be difficult.
“The community is desperate and there just aren’t enough providers out there,” says Dr. Hong. “If [CARES] had more staff, they could serve more people.”
Some of these issues may be addressed now that Michigan is becoming a Certified Community Behavioral Health Clinic (CCBHC) demonstration state, which “will allow us to do this even longer and expand the program even further,” says Harding.
“There’s a lot more that is needed,” says Dr. Hong. But, “the bottom line is, [CARES] has been a lifeline for many. Not only for individuals who have mental health issues, but also for mental health providers who know that twenty-four-seven, if they are concerned about a client, they can contact the crisis team and they can do a face-to-face evaluation. That’s very comforting for therapists and psychiatrists.”