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The psychiatric emergency services (PES) virtual clinic at St Joseph’s Healthcare in Hamilton, Ontario, is an innovative program established to enhance access to psychiatric crisis follow-up care during COVID-19. The clinic provides follow-up video or phone calls to patients who were discharged from PES and who require mental health follow-up at a time when services are difficult to access. Social workers are imperative to the clinic, bringing their knowledge of community supports and their specialized skills in psychosocial assessments and crisis counselling. The PES unit is part of the emergency department (ED) and plays an essential role in the community. It provides specialized acute care for multiple psychiatric emergencies, such as psychosis, self-harm, suicidal ideation, acute substance intoxication, and situational crisis. After being triaged through the emergency department, patients who are referred to PES are provided with a comprehensive mental health assessment, support, addictions screen and risk assessment, discharge planning, and crisis planning; referrals to the most appropriate level of care, such as inpatient admission or outpatient services, are also made to ensure continuity of care.

During the COVID-19 pandemic, access to hospital and community mental health services have been limited due to social distancing regulations. These regulations perpetuated challenges for individuals who required emergency psychiatric services such as follow-up care, medication renewals, crisis supports, and case management. The situation was further complicated by limited access to social support systems—family, friends, work, and other social activities—and, as time went on, PES staff voiced concern for the potential deteriorating mental health of this population. At the beginning of the pandemic, patient volumes were low, but over time numbers increased. In addition to the higher volumes, PES staff observed that the acuity of the patients presenting to PES was higher than before the pandemic. This paper will discuss the pros and cons of implementing virtual care follow-ups after emergency psychiatry discharge. We assert the need to use existing telepsychiatry tools for simple post-discharge interventions from an emergency psychiatric setting during these extenuating circumstances. The need for a service such as the PES virtual clinic during these unprecedented times becomes clear after reviewing the literature relating to mental healthcare emergency options and patients’ needs.

The Innovation and Evidence So Far

Psychiatric Emergency Department Visits in Ontario

In Ontario, prior to the COVID-19 pandemic, 22% of ED return rates were related to mental health, and 32% of ED return rates were related to substance use (Addictions and Mental Health Ontario, 2018). Often, revisit rates are due to patient needs not being satisfied in the community, due to waitlists, poor medication compliance, a lack of follow-up care, and other unmet social determinants of health (Gutkin, 2011; Canadian Mental Health Association, 2008). In the past seven years, Ontario has observed a 13.4% increase in psychiatric care needs, such as ED visits associated with mental health and addiction, and Health Quality Ontario expects these visits will surpass an additional 30% in the next 25 years (Medeiros et al., 2019). On average, patients wait sixteen hours in the ED, while psychiatric patients wait two hours longer for care (Health Quality Ontario, 2018; Atzema et al., 2012). The PES virtual clinic is beginning to address these issues while providing accessible care to patients during the COVID-19 pandemic.

Follow-Up Care for Psychiatric Patients

The days following discharge after a psychiatric admission can be a vulnerable period for patients and their caregivers. Studies have explored interventions after discharge from ED or acute mental health units with overall positive outcomes for patients (Tyler et al., 2019). Follow-up shorty after discharge from ED has been demonstrated to reduce the risk of suicide (Exbrayat et al., 2017; Miller et al., 2017). Subsequent controlled studies by other teams showed reduced revisit rates, especially in the first week following discharge (Exbrayat et al., 2017; Cebrià et al., 2013). Despite these findings, the wait for psychiatric follow-up care in Ontario has increased from 19.3 weeks in 2018 to 22.7 weeks in 2019 (Barua et al., 2018; Barua & Moir, 2019). Moreover, Canadian studies have mainly focused on the patterns of patients discharged from acute psychiatric inpatient units, leaving a gap in research concerning discharges of patients who have presented to ED or PES (Tyler et al, 2019).

Virtual Care as a Service Delivery Option in Emergency Psychiatry Departments

A broad range of evidence supports the use of virtual care in emergency psychiatric settings. Research has shown that mental health interventions provided over the phone are a viable alternative to conventional face-to-face therapy (Dombo et al., 2014). Offering virtual care options in emergency psychiatry departments can reduce patient wait times, overcrowding, and overall costs of bed occupancy by reducing inappropriate psychiatric admissions (Hensel et al., 2020; Salmoiraghi et al., 2015). Virtual care minimizes transferring patients for consultation, allowing patients to receive care in their home hospital and community (Simms et al., 2011). Despite the acceptability of virtual care, it is underutilized: studies have concluded that a disproportionate number of patients require mental health supports following a hospital discharge (Serhal et al., 2017).

Minimizing Suicide Risk

Research has demonstrated that the days following discharge after an emergent mental health event can be a vulnerable period for patients and their caregivers. In response, studies have explored interventions after discharge from ED or acute mental health wards with overall positive outcomes (Tyler et al., 2019). For example, the multi-centre ED-SAFE Study in the US showed brief follow-up interventions decreased post-ED suicidal behaviour (Miller et al., 2017). An earlier randomized controlled study by a French team showed that psychiatrists contacting people one month after ED discharge was significant in reducing the number of re-attempted suicides over one year (Vaiva et al., 2006). Subsequent controlled studies by other teams showed reduced return visits, especially in the first weeks post-discharge (Exbrayat et al., 2017; Cebrià et al., 2013). Canadian studies have mainly focused on the effect of discharge from acute psychiatric inpatient wards, and we are not aware of Canadian studies of the period post-discharge from ED or PES (Tyler et al., 2019). Overall, there are calls to better utilize emergency care to extend investigations into post-discharge health outcomes with robust methodological approaches (Guzman et al., 2020; Larkin et al., 2010).

Psychiatric Needs and COVID-19 Pandemic

Mental health service disruptions related to COVID-19 protocols are currently overlooked in research, despite past infections’ legacies of increased rates of psychiatric illnesses, notably PTSD, anxiety, and depressive symptoms (Torales et al., 2020). Throughout our survey of relevant literature, we found little research to inform the implementation of virtual care in Canadian healthcare emergency services (Hensel et al., 2020; Serhal et al., 2017). More specifically, there is a void in research regarding a collaborative psychiatric and social work care model for use in the context of a global pandemic.

The COVID-19 pandemic has created global uncertainty, causing a ripple effect of multiple system disruptions. In Canada, the Public Health Agency has implemented strategies to reduce the risk of infection, including isolation of those infected or at risk, social distancing, and simple hygiene techniques (Prem et al., 2020). These restrictions have impacted individuals’ social support systems and access to mental health and addiction support (Prem et al., 2020). The COVID-19 pandemic also has added additional pressures to a mental health and addiction system that is already overburdened (Health Quality Ontario, 2015). This additional pressure was a catalyst to ensure that we reimagine emergency psychiatry, making certain that we are meeting the needs of patients during these uncertain times. The pandemic has thus re-invigorated interest in telepsychiatry as a means to meet the growing challenges of mental health while practicing physical distancing. We believe in the need to re-discover and leverage telepsychiatry methods in emergency psychiatry. PES and our emergency medicine colleagues are critical front-line links for mental health patients during the ongoing phases of the pandemic.

Considering these circumstances, virtual care has become essential in order to meet the regular and increasing needs of intimate partner/child violence, substance use, and suicide. This increase in needs is in context of warnings of an echo pandemic: a mental health surge perpetuated by record-high unemployment, delayed elective procedures, and disproportionate negative impacts on marginalized populations (Canadian Mental Health Association, 2020). Because of these current and looming risks, we believe there is a need to leverage virtual care methods in emergency psychiatry programs.

PES Virtual Clinic Process

The PES virtual clinic is an innovative clinical program that was established to support patients with the aforementioned issues and to facilitate access to psychiatric crisis follow-up care. This clinic consists of a multidisciplinary team that includes social workers, registered nurses, psychiatric residents, and a staff psychiatrist. The clinic provides psychiatric follow-up via scheduled phone or video calls for patients who have been discharged from PES. The PES virtual clinic provides individuals with emergency psychiatric care, with the goal to provide a service that is effective, safe, accessible, and timely. The clinic provides diagnostic and risk assessments, medication reviews, bridging appointments, brief counselling, and a variety of other interventions that relate to each individual patient’s mental health needs.

Patients are referred to the virtual clinic following discharge from PES. A typical process through PES is a referral from an ED doctor for a mental health assessment by a social worker or registered nurse, followed by a psychiatric evaluation and treatment, and finally a discharge plan. The PES team will identify patients who will benefit from a virtual clinic referral. Some examples of reasons for referrals are subsequent risk assessments, medication efficacy or monitoring, further disposition planning, and bridging care until the patient is connected to other outpatient services. The clinic has low-barrier referral criteria to ensure that more patients have access to this bridging service, with the goal of reducing unnecessary return visits to PES. Referrals for the clinic are for those who do not have immediate access to a mental healthcare provider, are willing to accept a call from the PES team, and can access a phone for the time of the appointment. An informational brochure detailing the process of the clinic along with an appointment date is given to the patient at the time of discharge from PES.

On the day of the appointment, the referral is reviewed by the virtual clinic intake team. The patient is first contacted by a social worker or registered nurse to assess and evaluate the specific needs as identified by the PES team, such as a subsequent risk assessment, evaluation of symptoms, substance use, or any other issue relating to the patient’s mental health care needs. After the initial assessment, the social worker or registered nurse reviews the clinical information and provides input for further treatment and disposition planning with the psychiatric resident and staff psychiatrist. After consultation with the multidisciplinary team, a member of the psychiatric staff will contact the patient and review their case and the specific crisis that brought them to PES, and they will work together with the patient to ensure the disposition plan is meeting their unique needs. These follow-up appointments are typically scheduled within a week of their PES discharge. That said, to mitigate unnecessary visits to PES, patients in crisis are told that they can contact the team prior to their scheduled appointment.

The PES virtual clinic is able to provide approximately four appointments slots a day. In addition to supporting patients who have been discharged from PES, the team provides consultation to regional hospitals, family physicians, and community organizations that do not have access to psychiatric consultation. Currently, this clinic has been staffed using current allocated resources, without hiring new staff.

The Role of Social Work in the PES Virtual Clinic

The social worker has a multifaceted role in the PES virtual clinic through initiating initial assessments, collaboratively developing follow-up plans, and facilitating community care. Social workers are ideally situated to support the goals of the clinic, as they bring their broad knowledge base, adaptable skill set, and crisis intervention experience. Social work skills often used in the PES virtual clinic include brief therapy, discharge planning, risk management, and environmental assessment to gain enhanced understanding of the social problems affecting patients.

In the context of the COVID-19 pandemic, understanding the disruptions and modifications that social services have undergone has been essential in helping service users. Changes in these systems happen frequently, and patients are often unaware of service disruptions. As a result, advocating for patients and supporting them to navigate the healthcare system has been a crucial task for the social work team during the pandemic. In studies of social work in emergency care, lower rates of hospital admissions are reported when social workers are involved in care than when they are absent (Barber et al., 2015). Social work has a similar impact in the PES clinic, which is of upmost importance during the COVID-19 pandemic.

Limitations of the PES Virtual Clinic

Limitations for the PES virtual clinic are upfront financial sustainability, training, and accessibility for team members experienced in mental health assessments. There are barriers to populations such as those experiencing homelessness, who might not have easy access to phones or computers. There are also patients who prefer meeting in person. There may also be a risk of overreliance on the virtual clinic instead of community programs and outpatient services.

Benefits of the PES Virtual Clinic

There are multiple benefits of virtual care following the discharge of a patient from PES. These positive outcomes are improved patient satisfaction post-discharge from ED/PES, improved engagement to primary and outpatient services, and reduced presentations to PES. In addition, virtual care mitigates potential trauma that ED visits can cause (Canadian Mental Health Association, 2008). The clinic meets the provincial agenda to reduce ED visits, wait times, overcrowding, and inappropriate admissions. Simultaneously, the program addresses patients’ unique psychiatric needs and psychosocial issues of health in an acute care setting. The program aims to provide bridging appointments for patients that are on waitlists for psychiatric care in the community, while attempting to alleviate further crisis and reduce caregiver burnout.

The collaborative approach used by the PES virtual clinic team fosters interdisciplinary collaboration and strengthens existing relationships with community partners, regional hospitals, and other healthcare professionals. The day-to-day operations of the PES virtual clinic are financially cost effective. Follow-up appointments at the PES virtual clinic are brief, with a goal to reduce non-critical visits to PES, ultimately freeing up time for the team to support patients waiting for emergency services. Cumulatively, all of these factors minimize exposure and spread of COVID-19, making service delivery safer for clinicians without compromising care for patients. Such low-barrier, short-term interventions have shown to reduce suicide risk and re-attempts, and likewise have shown potential for cost effectiveness and improved patient experience. This re-discovery and flexible use of telepsychiatry in emergency settings highlight scalable, straightforward innovations to meet the growing needs of mental health during forthcoming phases of the pandemic and beyond.

From a public health perspective, visits to the emergency department were avoided and exposure to COVID-19 was minimized. From a hospital perspective, admissions have been avoided and the pressure to provide safe space and resources for this type of assessment was relieved. During the COVID-19 pandemic, access to PES has been limited due to social regulation issues. At the start of the pandemic, there was an uncertainty in regards to the process of transferring patients back and forth between facilities. During this process review and the implementation stage of learning and problem-solving related to COVID-19, PES staff wanted to continue to support our external hospitals while also reducing the spread of COVID-19.

Conclusion

The COVID-19 pandemic has created challenges in providing psychiatric care for patients. The need for our recent re-orientation to telemedicine during the COVID-19 pandemic is clear, as it provides access during a remarkable disaster and provides engagement while maintaining physical distancing from our clinics and hospitals. We hope that virtual clinics post-discharge from ED or PES will spur research and inquiry on the importance of psychiatric emergency as a critical front-line artery to primary and outpatient care. Further, robust studies are needed and encouraged on emergency psychiatric settings as prevention sites of mental health crises. We hope this pandemic incites rigorous research such as mixed-method studies with longitudinal analyses to articulate gold standards of emergency psychiatry care for our mental health populations. We hope that virtual care can streamline the often-fragmented mental health service systems post-discharge and that our virtual clinic act as a template for other emergency departments. We also hope such interventions re-frame our emergency psychiatric roles as part of an overall process of prevention and in re-discovering existing strategies to lessen the stigma and provide creative public health approaches to our mental health.