A lot of the mental health patients are not really being treated in the emergency department because they tend to say, well, we're going to we're going to look at you later, we're going to transfer you and you're going to become an inpatient.

But if you think about that in relationship to if you show up with asthma, they don't say, hey, you know what?

We're going to watch you.

We got you.

We're trying to find a bed for you in an asthma hospital.

So just sit tight for a couple of days.

You can hang out here.

They would never do that.

And I will say, I work with Dr. Scott Zeller on these guidelines.

He's been very beneficial to the FBI and the health Guideline Revision Committee.

So when I make clinical statements, it's items that I have learned from from Dr. Zeller.

So there was there was an approach where communities health care systems have been pairing together.

Sometimes it's different health care facilities and systems joining.

And they said, well, we'll be we'll build a community crisis center.

And then mental health patients won't come to the emergency department anymore.

The problem is this is good that they exist.

They're important for the continuum of care, but they are.

There are certain patients that they exclude from coming to those.

So if you're active with substance abuse, you are violent.

You have a medical issue along with the mental mental health issue.

serious developmental disabilities you come to too frequently.

They're worried about severe suicidal ideation and you won't if you won't take your medication, that they won't allow you to to stay there.

So for those reasons, we still have people that are in more of an acute crisis.

They can't show up at those facilities.

So they're still going to the emergency department.

So then there was the idea that Dr. Zeller had that why don't we treat mental health patients in the emergency department like we do everyone else who who goes there.

So the emergency department has to take everybody.

They have to treat them.

So there's there's more equity.

They they they define them as emergencies just like any other kind of medical emergency.

So it's the door that you can that you can come to.

So when mental health patients go to a typical emergency department with that doesn't have a special path for the behavioral health patients, it really bogs down the flow of the patients.

It takes more resources.

If you have a patient sitting there waiting for an inpatient bed, they might be taking up an exam room for days or end up boarding in the in the hall.

The their length of stay is usually longer because the care the right caregivers aren't necessarily in that in that space.

And they just take more resources in general than than typical medical patients.

So the thing that happens then is it prevents turnovers.

So it not only slows down the care for the mental health patients, but for all patients within the emergency department.

And then that means there's a financial loss to the emergency department.

When you're boarding those patients because you don't have the turnover and sometimes patients will go to to a different emergency department to to move on.

So basically, it really makes up the work.

I mean, the care for everybody who's who's going through through that.

So it used to be that, there would be one exam room that you needed to have per, per FTE that was available for behavioral health patients.

Often that would be that room would have a coiling garage door in it so that if a behavioral health patient was in that room, they wouldn't be able to hurt themselves on any of that that medical equipment so you could close it down.

So one patient, the numbers of people that are coming to the emergency department now for mental health care, that's just that's not and that's not enough enough space.

So, and what if what if the emergency department room is larger?

Right.

So this is a this is a larger emergency department.

It has 47 exam rooms.

So they made a separate psychiatric holding area, but it was still based on that previous model.

So they would gang all those exam rooms together in a space so there could be a secure vestibule, vestibule or a sleepwalk in that area to keep those patients together.

But they're still in a room by themselves, isolated.

And if you're having a psychotic break in, hearing voices and not trusting people and you hear somebody laughing or talking outside the room, you might think they're talking about me.

They're laughing about me.

And it it really keeps you in that in that crisis mode.

And you feel more like you're you're in a cell and you feel very alone.

And maybe they even chemically restrain you because you're being agitated.

And here you are and you feel, maybe not physically attacked, but mentally attacked, especially if you've, you've, you've gotten a shot.

Maybe you came here and you were you were dropped here by the police.

So it's a very traumatic event.

so and you're still not necessarily being treated here.

They think you're probably looking for an inpatient.

Well, just like when you go to the emergency room for some kind of medical issue, you don't necessarily need inpatient care.

You need to be stabilized in that environment.

You need to have a follow up appointment set and medication balanced.

And so the staff only coming in certain times to to see you, but they can't really see you unless they're they come into that into that room.

So this was another facility solution.

So it was a segregated area as part of part of an emergency department.

It had some individual exam rooms, but it also had some recliner bays where they could have the curtains drawn if they wanted or they could have the open.

It was right across from the nurse station that had the medication area.

So this was specifically for emergency.

care for mental patients.

they had an area for personal belonging.

You had a security, office for just inside this unit.

And they actually also had a little seclusion area in case somebody was so agitated that they needed to be to be restrained that they could do that in this area.

So in order for this to be this to be built, they had to go and talk to the Department of Health because the Department of Health said, well, no, no, I don't know where these patients are different.

We need to have in an exam room for each of these patients.

But so the clinicians had to go with the architects and engineers and meet with the people at the Department of Health and explain why this was a different patient population, why it would make sense to to have those different different care areas as opposed to the individual rooms.

So I was aware of this, of this project.

And then I went to another state.

I was in Colorado.

a firm that we were working with, had a project.

They were expanding the emergency department and they also had a sub area similar.

It was different than this, but it was similar to this.

And they had the same experience where they had to take the clinician to go explain talk with the Department of Health about it.

And, and I knew that 80 boarding and mental health was an issue before that.

But when I saw that health care systems were coming up with ideas and trying to come up with a solution, I, I wrote to the president of the FBI at the time and said, here's an outline.

I think that we need a special behavioral health emergency department that is separate.

And these are the elements that I think we need to include in that.

And he said, yes, that's a great idea.

You're the chair of the topic group.

So so I volunteered myself.

But it's been it's been a great experience.

So I'm so glad that that I did.

So I didn't know who Scott Zeller was at the time I wrote that outline.

but Dr. Zeller, I think around 2000, in 15 or 16, he came up with what sometimes was originally known as the aluminum model, his emergency psychiatrist in in Oakland, California.

And he said, Why don't we treat the patients just like we treat all the other patients?

we have to make sure that we and these are his goals for emergency psychiatric care.

So we have to make sure that, the patients are medically cleared and they are medically stable.

we want to rapidly stabilize the acute crisis.

We want to avoid coercion.

So not, physically, hold people or give them shots to chemically restrain them.

And we want to want to treat in the least restrictive environment so a more normalized therapeutic environment as opposed to everything being locked down and you being watched with it with a camera.

And really that the clinicians form a therapeutic Reliance alliance with, with the patients.

and then as they're, they're constantly observing, observing the patients, checking to see if medications and other discussions they've had have made a difference.

because sometimes it's patients coming in who have stopped taking their, their medication and they really just need to get back on their, on their medication.

And so before they leave, they put a plan together and, and then they can go and have have follow up care.

And it's very, very specific.

rather than sending them to an inpatient room.

So the Empath model stands for Emergency Psychiatric Assessment, Treatment and Healing.

So people come in, they review them.

This is the destination.

Just because you come to the behavioral health crisis unit doesn't mean that you won't be an inpatient if that's appropriate for that patient, that that will happen.

there's designated staff that will work with with you that are trained specifically for this patient population.

And they have that constant, observation.

and it's really more of a calming healing environment and not chaotic that like a traditional emergency department will be.

And it's more of a wellness and recovery approach.

So the physical space is, is larger.

it's more like 80 square feet, not around the recliner area, but for the whole department supporting, supporting this area.

So not only is it that physically calming environment, but there are multiple peers that and, and staff that will work with you.

So there's psychol.

Psychiatrist Social workers.

licensed, practical, practical nurses and techs.

There are also peer support specialists.

So somebody who's been through their own mental health crisis and now work with other patients to help them see where this journey is going to going to take them.

it really makes a big difference.

I know culturally some different populations are like, I can't do that.

My, my family will think I have no machismo if I, if I go and seek help.

So it's bringing that real lived experience to help the patients and understand how, how they can be cared for and, and heal.

And so it's really the reduction of, of stigma.

So this isn't an institutional looking area.

So sometimes there are, there are nature photos.

If you can have windows, that's absolutely wonderful.

Full If you can have windows in the space, there would be a quiet room so that if somebody realizes I'm getting I'm getting really stressed, I need to to be by myself, that they can self-select to go into into that room.

And again, they they they, they don't feel alone.

And if they see somebody talking to somebody else, they can see that they're talking to somebody else.

They're not talking about them.

So it's it's definitely a place of comfort from that.

So this model is growing across the across the United States in the FBI, we called it the Behavioral Health Crisis Unit.

if you've seen one of them, you've seen one of them because depending on the system, the space that you have available to, to do this, to do this work, it just, it just can vary a lot with what the system is want to do and what they need for their patient population.

So, there's many dozens of these units that have been built now and then there's more that are in, in construction.

And the Joint Commission actually thinks this is best practice, which is great.

And again, this is just a piece in the continuum of continuum of care for mental mental health patients.

So I'm going to look at some example plan.

So, this is a smaller scenario, but it contains a lot of the elements that, that we put in the guidelines.

This was built before the, before the guidelines.

and thanks to Dr. Zeller for, for, for sharing this plan.

So they have a special waiting area and security as you come in, there's a small intake room where a patient would have a conversation with the.

The patient.

there's a resource center, where staff.

And if, if they would allow a patient there, they might to like, help find a placement for this patient for the outcome services.

and then there's a public toilet in it and a staff toilet and then you walk.

There's a, there's some lockers there, adjacent to, the door into the middle you area.

And that's for patient belonging.

So there are certain things that they might bring into, this location, and they're, they're worried that patients might, you know, try to harm themselves and, and get contacted by friends that are maybe enabling, some of the issues or they're going wrong.

So they, we have to have space for that.

we also include a shower in these areas because some of these patients are going to be homeless patients and they need to be able to be cleaned up and, and and take care of care of that.

Of course you need things like janitor closets and whatnot.

in this place, you know, in this location, you'd have to have it be a locked room and whatnot.

and then there's a nurse care station that is open to the mildew area or that or that common room.

And then a patient gets a recliner.

They're.

They've been examined in that in that intake room.

And they also have a place to sit and maybe play cards or or maybe that's a little group discussion that they could have there or play some games.

And then there you see that there's a nutrition area so that that clients can get sometimes, sometimes only interchange clients and patients, because depending on the health care system, they they will call them either either one of those names.

And so this nourishment area has you can get your own drinks usually and and some snacks.

So it has a refrigerator so people can feel, agency so that they can be in control of their environment somewhat.

So they, so they'll go and do that.

and then there's additional patient toilets.

a laundry room is in this, in this facility.

they've called the quiet room.

In this case, the, the cool room is sometimes it's called a comfort room or a cooling room, but that's that room of self-selection to get away from from the larger group of people when you need that time to decompress and be alone.

and then they have a semi-private room.

So if someone, you know, needs to have a little quieter time in there, but rest, maybe they want to rest and, and sleep that they can go into that space.

and then their shared office for staff here, you'll notice that behind the nurse station are a medication room, a clean utility room, and also a soiled utility room.

So those need to be, really associate aided closely with the nurse station and not readily available for, for patients because we worry about some of the safety.

And then there's a consult room.

So if, one of the psychiatrist or, caregivers needs to have a private discussion with the patient that they can, they can step into that, that private, private room.

this is an example plan of the University of Iowa health care system.

They were in early adopter of the impasse model.

but they're growing.

They're growing numbers and system is requiring them to move out of their existing impact model.

But they knew what a huge difference it made to have that, to have that separate path for behavioral health patients.

So they were committed to replacing and expanding that unit.

So the first floor of the unit directly attaches to the emergency department.

They have some specialty triage rooms, specifically for behavioral health patients.

Their behavioral health safe, but they're adjacent to their other triage areas and they can be opened up and utilized if you need to use them for that for the the other medical patients.

we have the lockers a special changing area because some, some not all of these facilities require patients to change into to a gown so that they can't keep and do a what's referred to as a skin test to make sure they don't have any, contraband on them.

or potentially weapons.

I've heard of patients that have, razor blades taped to the back of their legs that they use for they get a substance abuse problem.

And so they used it for, for cutting drugs and then they can hurt themselves with it too.

So finding those kind of things is very important because you don't want them to be brought into, into this unit.

so since this unit is, immediately adjacent to the emergency department, there was definitely consideration about we want to focus on this being a behavioral health safe space, but what if we have another pandemic?

What if we have some kind of emergency and we need some of these spaces?

So, we actually have some of the rooms that are going to be, swing rooms so that if they are needed for a typical exam, you could do that.

So, you'll see that some of the, some of the rooms do have the, a space for the garage door.

So they have the sink in there and the medical diagnostic tools and, and med gases behind that.

we have a sexual assault room within this area, so it has to have an immediately adjacent bathroom accessible from, from the room.

And clearly, that would be a very traumatic event.

So, they had this room in a different part of the emergency department, but they thought it was very appropriate to have it in this, in this part of part of the plan.

And again, the nurse station with the medication room and the clean supply room behind that behind that room, they they do have a seclusion room.

because they wanted to make sure that they have that they're saying that the level of acuity of people that are coming to the emergency department is ratcheting up and they want to have that available to them.

There's a separate area that staff can go for, for a break room.

and their own and their own toilet and then, because this is a real world plan, they also had a need for additional MRI for, for the health care system, in close proximity to the emergency department.

So the tail end of the, of the plan has that.

So we're, I'm gonna jump to the second floor and you will see that this is probably what you're expecting and sorry the columns aren't really there in the, in the corridor.

That's some kind of graphic error.

So as you come to that, to the second floor, there is a crisis unit for adults.

That's the larger unit.

And on the other side, there is a crisis unit for adolescents.

when you're younger, I think the, the age was, was 12.

If you were younger than 12 and your behavioral health patients, you actually went to the pediatric area of the emergency department and they had a special area for those for those age groups.

But when they got to be, a little bit older, they had an adolescent area.

And so you want to separate those adolescents from the from the adults, but you want to make sure that we have efficient, efficient planning.

So they are sharing the nurse station visualization, is separate, but then they have those support spaces in the middle of the, of the care station.

So that, that, so that it makes for an efficient plan.

and in this case, they wanted to make sure that nourishment if the the, the dining for the hospital came and dropped off some meals that they didn't have to go into the meal use space at all.

and interrupt the nursing area.

So we have double access for, for several of those rooms and then we have consult rooms off of this, this public corridor too, so that they can be used by either the adolescent or the or the adults.

The other thing is sometimes they will bring family members in to have a meeting with the patients and the staff.

They don't want the family members to go into the middle area because that would be disruptive.

So that's why we we kept those accessible, off that corridor.

And then within within the military area itself, you, you can be seen by people in the nurse station.

Again, that staff is they have, we have, we have several seats there, but that staff is really intermingling with the patients so they can observe them and see how that that treatment is going.

And if the patient is is improving.

and then we have a couple quiet rooms off of that for them to self-select.

we have some patient bathrooms, and a seclusion room and one of those, one of those bathrooms has a, has a shower in it so that the patients would be able to, to shower and then similar areas that are off of, of the adolescent area and then we have the staff rooms that are a little bit down the hall but that house offices and have conference area for the staff in this area that is outside of the patient area that allows you to use regular construction materials and not the special behavioral health safe products that that we would use in a in single rooms that that are for the for the outpatient.

How am I doing on time?

Wow.

Okay.

So I'll this real quickly talk about the sample outcome.

So they're saying that Q Huge, huge drop in EDI boarding and the amount of time that patients stay in the emergency department reduction in 70%, improvement in outpatient follow ups because it's really had, the patients feel safe, they've had a good first interaction as they've come to be treated in here, so they're okay to come back again as opposed to maybe the previous more traumatic situation.

and then, and so people tend to tend to come back and not revisit the emergency department because they're engaging with those follow up outpatient care.

And it, it, it added a huge amount of money to, to the bottom line of the emergency department.

And because of that, turnover that's allowed now by having this separate patient population.

So it's better for the behavioral health patients and it's better for all of the patients in the in the emergency department and it doesn't matter.

They've kind of proven at this time, it doesn't matter what the size of these units are.

They still have, you know, a huge amount of the patients like 75% or more, get to be discharged because it was just an emergency.

They didn't actually need inpatient care.

the average length of stay went down.

And because this wasn't coercive, trauma traumatic, you know, care in this chaotic environment, there was less injury and way less restraint needed to be needed to be used.

So it's really a win for everyone.

more numbers that, that are showing that you're really saving a whole lot of money.

So these units really pay for themselves.

there was a great article in the New Yorker, and I love this, this quote, you can read it, but that it's not just procedures and medications that can make a difference in medical care, but that spaces can be therapeutic.

Also.

So time for questions and answers.

Thank you.

Yes.

I think takes us out of here.

I'll let you do What's your name, please?

Hi.

So when you initially sent the policy recommendations, how did you develop those?

Had you worked with that population before?

so, we had the, the topic group had a number of, subject matter experts.

Some of those people were architects.

Some of those people were clinicians.

Dr. Zeller was our key clinician.

We had another physician who was an emergency department physician.

we also analyzed, plans that we had seen.

So the, the one project that I showed that was, you know, along the lines of like moving towards this, another, another plan that we, that I saw in Colorado.

different architects and authorities having jurisdiction were also part of that committee.

So we had a good cross section of people that had engaged with, with these and, analyzed those plans and then put together multiple drafts.

And it, it just came together over time.

We also had public proposal period where people commented on what was and was not in the unit that we had proposed.

it was great having an authority, having jurisdiction in our group.

So they might say that's really not enforceable.

It's wishy washy.

we have a lot of those discussions in the FTI, it sounds good, but it's really not enforceable, so.

So I'll say that's how they, that's how they came about.

Thank you for the presentation to start off.

But my question was in regards to the idea that you had brought up where they had like peer supported stuff, so individuals you had mentioned that had already perhaps gone through the treatment and are coming back now to assist.

I was curious, if you have numbers like how have you seen that improving the patients that are, you know, able to have that peer support.

So I don't have specific data on that, but it makes a huge difference in as far as the follow up of, of patients.

we did a reimagining psychiatric emergency care in, in combination with the newbie conference that is the national update on behavioral emergencies and there were I think I'm going to say, let's say there were eight tables and each of those tables had a peer support, a physician, and, and designers, maybe an and a definitely h JS were in the room.

and those of us that, helped plan some of these reimagining would facilitate that discussion.

and I lost, I lost my train of thought, but that, that peer, that was the first time I interacted with the peer support and it was so these are people, this is their full time job now because they interacted with the health care system and it made their lives richer and it helped to them.

And so they thought it was really important to be part of that, part of that conversation.

and that's where I got some of the, you know, thoughts about the cultural understanding because there's this stigma about getting, getting help for mental mental health.

So I know that some of the peer support people, they said it was really hard for me to go and get this help.

And I don't want somebody else to not go.

I want to be there to help support them and say this is a crisis.

And you can get you can get through this whatever your specific path might be.

Thank you so.

Thank you so much.

Any other questions?

I would also like to thank you for speaking to us.

My question relates to excuse me, Dr.

Goals that you mentioned.

And that is the question of it said like basically restrict the, patients.

So if a patient has a behavioral mental health issue, could they enter into a specific crisis unit?

I think that would be, a health care systems, decision on whether they could manage that or not and have the appropriate staff.

certainly not in community care.

They, because they tend to exclude those.

But since a lot of these are immediately adjacent to the emergency room, they could, they could have a medical and a mental health issue and just as long as they are stabilized that they would be able to come in into this.

And then because there's this constant observation that that's happening, you know, they're able to make sure that that they are stable, both mentally and physically in that space, but it's going to be on a per patient basis.

Okay.

Thank you.

You're welcome.

Thank you.

Any other questions?

Yeah, I guess so.

For someone who's exploring the major, what kind of drew you more to?

Like the health architecture side of it?

well, I really think it's meaningful work.

So that that's an important factor to me.

I also, there's a certain amount of, you're always going to be learning that that really draws me to it.

It's, it's a complicated puzzle.

There's so many factors to take into account.

not just the patient well-being, but the staff's wellbeing.

and how it all works together.

It's a pretty integrated puzzle.

So that's, so I don't get bored with, with that at all.

there's also a financial stability and stability to this sector of, of health care, of architecture because people will continue to get sick.

There will continue to be innovations in care, They'll continue to be, new technology and radiology and any other kind of treatments and equipment.

And so, I think it allows you to keep, keep working as opposed to if you were doing developer work and the economy wasn't great.

So I so there was, there was that pragmatic reason that I, that I had.

also but that that continuing to learn.

I'm a very curious person and I think that this specific field really helps you to, to be able to continue to learn.

And it's, it's very engaging to me.

even though I've been practicing for over 30 years.

Welcome.

So come join us.

Well, I think we're at the end of our time.

Well, thank you so much, Virginia, for joining us.

It was such a pleasure.

And here's a small gift.

Texas A&M.

Thank you very much.

So help me.

Thank Virginia again.

Thank you.

This.