Use of a Novel Care Model to Reduce Behavioral Crisis Emergency Room Visits and Inpatient Psychiatric Hospitalization Length of Stay

Background: In patients with autism and other neurodevelopmental disorders, high patient acuity and limited outpatient care resources contribute to high emergency room (ER) visit rates while in crisis. This represents a significant burden to the healthcare system in terms of cost and potential for injury to the patient, family and medical staff.

Objectives: 1) To determine if enhanced outpatient care management was associated with reduced ER visit rates for behavioral reasons. 2) To determine if enhanced outpatient care management was associated with decreased length of stay.

Methods:

This chart review was approved by the Cincinnati Children’s Hospital Medical Center IRB. High acuity patients within our neuropsychiatry continuum of care were enrolled in enhanced care management. All enrolled patients had a diagnosis of Autism Spectrum Disorder (ASD) or other neurodevelopmental disorder and a history of significant healthcare utilization for behavioral and/or medical reasons. All patients received 1) outpatient nurse care management including frequent phone calls to families and care coordination 2) mental health specialist support in the outpatient psychiatry clinic and 3) efforts to provide direct admission to inpatient psychiatry when possible in order to avoid an ER visit. Utilized chart review to gather data from the first 47 consecutive patients enrolled in our enhanced care management program. Data on ER visits for behavioral health reasons and inpatient psychiatry hospitalizations was collected from patients for the year prior to enrollment in care management and at least one year post-enrollment.

Results:

Forty-seven patients with a mean age of 15.1 years (stdev 3.9) were included in this analysis. Enrollment in neuropsychiatry enhanced care management was associated with a statistically significant (p<0.0001) decrease in both the annual number of ER visits for behavioral reasons and the annual number of days admitted to the inpatient psychiatry unit. The average number of annual ER visits prior to enrolling in enhanced care management was 1.4 visits (range 1-8 visits, stdev 0.9). After enrollment in enhanced care management, the average number of annual ER visits was 0.5 visits (range 0-4 visits, stdev 0.6). Average annual length of inpatient stay pre-enrollment was 13.1 days (range 4-45 days, stdev 7.6), while the average annual length of inpatient stay post-enrollment was 5.6 days (range 0-22 days, stdev 4.9).

Conclusions:

Enrollment in the enhanced neuropsychiatry care management program was associated with a statistically significant decrease in annual ER visits, with an estimated annual cost savings of $103,400 ($2,200 per patient per year). The average annual length of inpatient stay was also significantly decreased with an estimated annual cost savings of $514,650 ($10,950 per patient per year). Future work will include assessing for changes in patient and family quality of life, and assessing injury reduction in the ER and the inpatient psychiatry unit.