Reinventing the E.R. for America’s Mental-Health Crisis

“In 2012, Scott Zeller, who was then the head of psychiatric emergency services at the Alameda Health System, in Oakland, California, was growing frustrated with the status quo. Many observers blamed long wait times for psychiatric patients on a sharp decline in the number of psychiatric beds in public hospitals. Zeller thought they were missing a more fundamental point. “Why is mental illness the only emergency where the treatment plan is, Let’s find them a bed somewhere?” Zeller asked. “If someone comes in with an asthma attack, we don’t say, ‘We’ve got a gurney here in the back for you. We’re going to try to find you an asthma hospital in a day or two, so sit tight.’ ” For psychiatric patients, this transitional time was therapeutic dead space—a missed opportunity. Could it be transformed into a period of healing?
Zeller converted an unused hospital lobby into a large waiting room. He supplied the space with snacks and recliners and organized group activities. A nurse or therapist provided counselling, and a psychiatrist tried to see patients and prescribe medications within an hour. “People said, ‘These patients will never be able to be in the same room together—they’ll just rile each other up!’ ” Zeller told me. “Actually, no—not if you create an environment that’s less like prison and more like a place of healing.”

This approach came to be known as the Alameda Model. After it was implemented, the number of psychiatric patients who stayed overnight in the area’s emergency departments fell almost to zero. In a traditional emergency department, as many as twenty per cent of patients experiencing a mental-health crisis might end up being restrained in some way; in Zeller’s unit, the number was 0.1 per cent, a difference that he attributes to the calmer environment and specialized staff. The average wait time in the emergency department for people with acute mental-health conditions dropped from more than ten hours to less than two, and, because patients received immediate attention once they got to Zeller’s unit, three-quarters were able to go home, where they tend to have better long-term outcomes, instead of being hospitalized. In 2016, Zeller renamed the model “EmPATH.” He was advised to copyright the term, but decided not to, so other providers could more easily adopt it. [..]

Even as the model gains momentum, there is reason to worry that a profit-based medical system can sustain only so much experimentation. For hospitals, an averted admission often means lost revenue; although insurance companies theoretically stand to gain from lower expenditures, they tend to reimburse for discrete one-time assessments, not the kind of holistic care that EmPATH units offer. “Insurers still don’t really understand what this is,” Zeller told me. “They say, ‘O.K., we’ll give you a few hundred dollars to see this patient.’ I’m, like, ‘That doesn’t even cover the security guard.’ ” Each year, in the United States alone, there are an estimated three-quarters of a million emergency-department visits for mental-health crises; to address the need, hundreds of EmPATH units, each one treating thousands of patients per year, would be required. Zeller is convinced that this can happen. “Every few weeks, I hear from someone wanting to start an EmPATH unit,” he said. “People see that the need is just enormous and the way we do things right now is completely broken.” [..]

When I first heard about EmPATH units, I assumed that their main contribution to mental-health care was empathy. This isn’t wrong, but it is incomplete. In my experience, nearly every caregiver aims to show empathy; the question is whether, in an emergency, we have the space and time to do so. In Minnesota, I started to think that the EmPATH unit’s real innovation is a structural shift in how we think about space and time. We usually consider drugs, devices, and procedures the kinds of medical care that make a difference, but physical spaces can be therapeutic, too. It’s also easy to forget that, in a crisis, every minute matters. Once a patient reaches an EmPATH unit, there are no waiting rooms: even if a patient is in line for a transfer to a longer-term facility, she is receiving care while she waits. “You have to capitalize on the moments when someone is motivated to change,” [therapist at M Health Fairview Southdale Hospital Kim] Mitlyng said. “You never know if you’ll get another chance.” What had appeared unusual about M Health Fairview’s EmPATH unit started to seem intuitive, even obvious: beautify bare walls, maximize natural light, strike a balance between privacy and company. A patient with choices—even small ones, like which snack to take from a snack bar—may wind up feeling a little better.”

Full article, D Khullar, The New Yorker, 2023.7.12