At Sentara Healthcare, a Bold Move to Re-Vision Behavioral Care Delivery
Back in 2022, a pause in admitting patients to the state-sponsored psychiatric health system in Virginia resulted in a statewide behavioral health crisis, with patients who couldn’t get help from the state-sponsored system descending on the states’ hospital emergency departments, lacking any other immediate source of care. Patient loads were dramatically increased, care was delayed, and medical patients were put at increased risk.
At the 12-hospital, 30,000-employee, Virginia Beach-based Sentara Healthcare, a not-for-profit system that serves patients across Virginia and northeastern North Carolina, Charles “Ken” Dunham, M.D., executive director of medical services for behavioral health and clinical chief of psychiatry for the health system, developed what was named the Behavioral Health Care Center Value-Based Model, which relieved the burden on the EDs, reduced costs and improved patient care for this population in need.
In partnership with Sentara Health Plans, the health system’s owned health insurer and which serves more than one million members, Dr. Dunham identified that one of the system’s Behavioral Health Care Centers in Virginia Beach could help significantly reduce overcrowding in the EDs, if behavioral health professionals could be added into the health system to quickly see and stabilize patients and refer them for follow-up care.
In addition to adding stabilization staffers to the ED, the Sentara Health Plan prepaid for “slots” for patients expected to be referred to the BHCC, allowing the center to staff up in anticipation of the greater patient load they would receive. Since the program began in early 2022, it has:
Reduced hospitalizations among behavioral health patients by 20 percent
Realized a 5-percent decrease in behavioral health patients initially accessing the ED for care
Reduced medical expense ratio for the health plan by 10-20 percent per behavioral healthcare patient
Decreased average length of stay in the ED for behavioral patients by an average of five hours
The program has been so successful Sentara plans to roll it out further across the system. A new BHCC location is currently under construction in Hampton, Va., and others are on the drawing board.
Per all of this, Dr. Dunham spoke recently with Healthcare Innovation Editor-in-Chief Mark Hagland regarding the advances made at Sentara. Below are excerpts from that interview.
Are you still in clinical practice?
Yes, I am board-certified in psychiatry and in internal medicine. My major role is with psychiatry and behavioral health, and my clinical practice is in psychiatry and behavioral healthcare.
How did the program originate? What were the conversations that had to happen at the outset, and among whom?
We have four psychiatric hospitals and see about 4,000 behavioral health patients a year; about 30,000 outpatient visits, and more than 20,000 ED visits. And we had twelve different facilities and EDs, and each had its own practices, per behavioral health. And then COVID-19 hit and sent a lot of people into telemedicine. And in the Commonwealth of Virginia, the state psychiatric hospitals, with complex psychiatric patients, had to stop taking new patients. And our patients started stacking up at Sentara. And the worst numbers came out in 2022.
So our leadership got together to do something different, and created an enterprise-wide strategy. I had come in in January 2023. And part of the strategy was to take the BH system and centralize BH and get to best practices. We also had five inpatient psychiatrists for Sentara and were unable to take care of satellite departments. So we found a third-party group, and centralized our licensed and unlicensed therapists—PERS, psychiatric emergency response specialists—they were all therapists—LPCs, LCSWs, some MFTs, both licensed and unlicensed, and unlicensed people worked under the licensed people. By the end of 2022, it was in the 30s, it’s currently in the 40s.
What does the structure look like now?
The structure is evolving. The structure became ED provider + PERS therapist; the PERS therapist would help do the assessment: inpatient, outpatient, etc. They’d also do some case management, getting patients to the right resources. And anything beyond that, we’d refer them to third-party telemedicine resources. And now we’re building out our own psychiatric hospitalist services. We currently have two; we’re using them to augment what the Array Telemedicine Partners are doing.
Do you have any metrics that you can share, per this program?
We use Epic, so we’re able to track when a consult is give in to a PERS, how long it takes them to respond, how long it takes a psychiatrist to respond, etc. We’re tracking ED lengths of stay; and it was an average of 23 hours in 2022, and it’s now 18 hours.
What have been the main reasons for the decline in the decline in ED length of stay?
Faster disposition of patients using a behavioral health specialist. Our licensed therapists are able to diagnose and make recommendations and give those to our ED providers. We’ve built trust there; they’re experts in navigating the system. It’s hard to navigate the behavioral healthcare system. There are a lot of legal issues for patients: are they being committed to a hospital against their will, for example? There are layers of complexity. The PERS group is able to help them navigate these complexities.
In short, by empowering the PERS specialists to the top of their license, that moves things forward?
Yes, they’re able to do assessments and make dispositions.
And the practicing psychiatrists didn’t feel threatened by the changes?
No; in fact, in psychiatry, because we’re so understaffed, we appreciate the help, especially in the ED. Not many psychiatrists want to work in the emergency setting; and there are very few specialized in it. And the therapists are now a part of the medical group, and we supervise them. Technically, they can do what they want, according to state regulations; but we have psychiatrists as their supervisors, and that helps.
What were the biggest challenges, of any kind?
The biggest challenge was getting everything centralized. We’ve had islands of good practice, of good resources, of lesser resources. But most of our PERS are now doing telemedicine; and after we gained the trust of people in the hospitals that we were here to make things better, we got things done, and they’re seeing the fruits of our labor. Making sure we’re treating all the hospitals fairly, allocating resources.
What have been the elements involving managing cultural change?
I think the hardest thing is that, if you have a psychiatrist already working in the emergency department, you can’t take that psychiatrist away and say, you’re going to have therapists now. But the majority of our hospitals really didn’t have access to psychiatrists, so adding in the third-party group of therapists was helpful. And we put in the PERS specialists, and allowed for if the emergency physician doesn’t agree with the PERS specialists, they can go to a psychiatrist. We’ve had 70,000 fewer hours of patients in the ED. Think about how much extra resources that would have added to staffing, to meals, to everything.
One of the issues with behavioral healthcare is that, compared to med/surg, patients stay longer. They’re 2-5 percent of the patients, but there are a ton of them. It’s like table turnover at a restaurant. In a certain way, that’s how EDs run. If you can get the patient to the right place at the right time, that’s important. It’s the equivalent of patients sitting at a restaurant table having coffee for hours and hours.
If the emergency physician doesn’t agree with the PERS therapist, the ED physician can ask for the psychiatrist?
Yes, and the PERS therapist can reach out for help, too. That’s why we contracted with a third-party group.
How many in the third-party group?
It’s a large array; a group of psychiatrists, working remotely.
What have been the biggest lessons learned in all this so far?
That you can get a return on investment by decreasing time in the ED, and by reducing the number of people walking out without being seen. The impact is soft savings. The 70,000 hours we saved, it ends up being about $6 million in savings when you figure out how much the system has saved. You can’t find that in a P&L spreadsheet, but it’s in there. You need a leadership that understands all the elements in this. That’s part of my job, to put those numbers in front of people.
People understand the clinical value and the need, but it’s harder to prove hard return. Now, we’re looking at AI to help us figure out—we saw about 10,000 patients in 2023 who got discharged home and didn’t seem to need a PERS assessment. We’re looking at patients who might be at lowest risk. The people at high risk are pretty much waiting for a bed; patients at lowest risk are just waiting to be cleared to go home. That low-risk person might just need their meds or an appointment. So we’re working on using AI to do triaging. And we opened a clinic to take patients out of the ED; we’re working on that with the health plan.
The clinic is open now?
Yes, it’s open and doing well. This is hybrid: in-person and telemedicine. That clinic opened in late 2022, and is the BACC—Behavioral Health Care Center). It’s in Virginia Beach. Headquarters.
It’s like an urgent care for behavioral healthcare delivery, then?
In a certain way, it functions in that way. The patients are already in the ED when we make an appointment for them in the BACC, decreases future ED visits by 20 percent. The other thing we did is that we found some patients couldn’t get there 8-5. If you’re a Medicaid mom with kids at home… We have afternoon as well as Saturday and Sunday appointments at the BACC as well.
