Every health system leader has unprecedented executive management challenges facing their organization in the wake of the pandemic. Some of those challenges, particularly in behavioral health, are access, throughput, and placement. Bringing to the show over 20 years of experience in healthcare operations and management to discuss the crisis we are seeing is Kenneth (K.C.) Johnson. K.C. is an accomplished business executive and entrepreneur with a proven track record of success in the healthcare industry. He currently serves as the Chief Executive Officer of HealthSource Integrated Solutions. He joins this episode to talk about how the industry can tackle some of the major access and placement issues that are occurring, beginning with the emergency room paradigm down to setting up a crisis stabilization unit. K.C. then shares his thoughts on technology and what he thinks it can do to help eliminate redundancies that keep patients from receiving the care they need as quickly as possible.
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Tackling The Crisis In Behavioral Health Access And Placement With Kenneth (K.C.) Johnson
In this episode, I’m joined by Darin Vercillo, the Chief Medical Officer and one of the executives at ABOUT Healthcare. We have an interesting program for everybody and it’s timely. We’re going to be discussing what I would consider to be the crisis in behavioral health access, throughput placement, and all the issues that I know a lot of you have been facing. We’re joined by our guest, KC Johnson.
He is the Chief Executive Officer of HealthSource Integrated Solutions, a shared services organization in Kansas. KC brings many years of experience in healthcare operations and management to his role as CEO. Prior to joining HealthSource, KC served as the service line director for behavioral health access and crisis intervention services at WellSpan Health, a large integrated health system based in York, Pennsylvania. In his role at HealthSource, he has been instrumental in developing strategic partnerships with key industry players, positioning HealthSource as a leader in the crisis intervention industry. KC, thanks a lot for joining us.
Thanks for having me. I’m glad to be here.
I was asked to give a presentation about the situation regarding pediatric behavioral health in this country. I was doing a lot of research for the talk. It was astounding to me when I looked at the changes that have occurred pre, during, and post-COVID. The numbers of kids in terms of the access issues, and as an internist myself and Darin as an internist in a hospital, this isn’t just a crisis in pediatric behavioral health. It seems to be a crisis across the board.
We have a lot in our audience who are in acute healthcare providing. They’re having to deal with this every single day, particularly in the emergency room. It starts in the emergency room for a lot of it, but it filters through the entire hospital experience. It’s putting unbelievable stress and strain on patients. I don’t think this country was ready for it. A lot of our readers who are in acute care, in particular, are wanting to know what you can give to them in terms of ideas regarding some of the major access issues that are occurring.
We’ll start with a question about that and if you could take a couple of minutes, let’s start with the emergency room because that seems to be a huge issue. Talk a little bit about how you believe the emergency room paradigm with regard to the behavioral health patient needs to change. That may be some comments about the environment to improve care for the behavioral health patient in the emergency room. It may also include some discussion about the medical clearance process and figuring out exactly how to identify quickly behavioral health patients and how to get them to the right destination.
I appreciated the introduction there. The pandemic has significantly exacerbated, but if we talk with a lot of acute care providers, they would say that there was a crisis in this area before the pandemic too. We’ve had patients sitting in emergency rooms waiting on behavioral health resources all across the country. I did some research on this before the pandemic. I haven’t done post-pandemic research, but the average stay for behavioral health patients in an emergency room many years ago was about 22 hours, which is significant when you think about the ED is key on throughput. If you have a patient that has a physical ailment that needs to go to an inpatient floor for physical health, typically the inpatient floor is at full capacity.
There are options to move them up there. There are a lot of different and more creative ways than occurring in the physical health space regarding this. I know there are still issues. We have a workforce that’s been worn out over the last few years. When you think about that, if you’re in a behavioral health crisis and you’re sitting in an emergency room for 22 hours, which is a chaotic environment that is lots of moving pieces, it’s not always peaceful.
Sitting in a chaotic emergency room for hours while in a behavioral health crisis puts a strain on not only the patient but also the emergency room nurses, physicians, and care staff. Click To TweetWe look at the strain that puts on the patient, but also the emergency room nurses, physicians, and care staff. In my previous role, oftentimes, I’m in communication with emergency room directors. When it comes to behavioral health and crisis, that is the paradigm that if you’re in a crisis, you go to the emergency room. A lot of places are all across the country. Law enforcement is taking people directly to the emergency rooms and dropping them off.
For emergency room providers who cannot turn away people, they’re being asked to keep people. One of the things when we look at solutions, there’s the long-term solution of needing more behavioral health resources, but that’s a long-term solution. The amount of beds that would’ve to be created or the innovation that would’ve to take would be significant. Often, when we’re looking at emergency rooms, we’re talking with them to say, “How do we think differently about the emergency room space? How are we thinking about what are those things we can do when they hit the emergency room to decrease those times?” A lot of the work that we’re doing with the ABOUT team is to address some of the barriers and roadblocks that happen.
Oftentimes, emergency room patients are in a similar type fashion. It doesn’t matter if you show up with a broken arm or in a behavioral health crisis, there are certain protocols that a patient goes through where you get triaged by the nurse, then you’re seen by a physician who might order some labs or do some things to start treating that patient. Oftentimes, because that emergency room doctor is stretched thin and when you’re emergency room’s operating at peak capacity, you have those delays. Some of the stuff that we did with WellSpan and they continue to innovate in the spaces WellSpan does, is looking at that paradigm of the medical clearance process.
If you have a healthy twenty-year-old adult showing up for behavioral health placement, the emergency room often has a lot of protocols set up that are standard based on somebody showing up with a medical presentation. There might be things that are done that maybe we don’t need to do based on their presentation. When you think about it, if a lot of emergency room care waits on the physician, meaning behavioral health often doesn’t get involved with a patient until the doctor sees them and porters a behavioral health consult. When you think about that, that could take ER stay from 3 to 4 hours just because you’re waiting for the ER doc to be freed up to see the person.
Looking at things in that process to say when the patient hits the door, the nurse is doing some suicide assessment. If we identify that’s the primary reason, getting a behavioral health consult in there to start with. By the time the doc hits the patient, they might have additional resources to help them make decisions quickly could help reduce time.
The one thing I would like to highlight when I work at WellSpan that was powerful and important was one of our emergency rooms in Lebanon County, there were some pretty innovative ER managers there. What they wanted to do was they wanted to create a part of the emergency room that was dedicated to behavioral health. They did a construction project and raised capital. The outcomes that were there, oftentimes we were pretty surprised by the different ways that it had positive impacts. They built a space that was ligature free and still had access to the emergency room services or the necessary things for emergency care, but it was staffed by people who had behavioral health backgrounds.
It was in a quiet part of the emergency room as separated off the main floor. There was access to things that you would see in a behavioral health unit. One of the cool things that we started looking in the outcomes and one of the amazing things to me that was positive was we saw a reduction in physical and chemical restraints of patients because they were not being agitated by the emergency room environment. Simply making that change. Reduce some of the burdens on staff and patient stress.
Darin, I know you probably have some questions, but I also would be interested in you. You’re still a real-life practicing hospitalist. You see this on the accepting end of the chain. I’m sure you have a lot of impressions on what you see that you probably scratch your head and you’re wondering how could this happen. I would like some of your thoughts similar to what KC presented in terms of the entry point, but also on the accepting point.
KC, you brought up some incredible points and some food for thought as to how you can creatively address the issues that are out there. Chuck, to your point, all of these thoughts and images were swirling in my mind. I was in the ER admitting a couple of patients. It was a very busy ER and overloaded. The hospital was full. They were backed up by boarding people there. I looked up at the board and saw where on the fast track and behavioral health side where behavioral health patients tend to be bedded in their emergency department. We experience numbers like 68 or 59 hours had been in the ER. The ER doc was running around crazy trying to address everything.
I remembered her turning to me and bemoaning the fact that this wasn’t what she signed up for when she became an ER doctor. I know it was patient soup and there was a lot that she had to deal with. Your thought there on this idea of when behavioral health patients come in that we don’t treat them like everybody else. They’ve got distinct problems. They may be completely physically healthy, but simply or in a focused way dealing with their mental health crisis at the time. I applaud you for the idea that we should track and process their initial stay in a different way. Chuck, you talk about the accepting end.
It’s very similar to a transfer process where we look at patients who have very specific needs that we can categorize and create an auto-accept policy where we don’t have to yank a physician out of surgery to approve this patient for transfer. If they meet all the five check boxes of being able to say, “We’ll accept this patient. Let’s move them on to the next destination in their stay.” What a great thing it would be if a behavioral health patient in crisis came into a triage situation and we could check all the boxes if we knew what was going on.
We could check all the medical clearance boxes so we didn’t have to get a physician to come in and say, “It’s okay. That crisis sees them now and they go on because they’re medically cleared.” What if we could skip that in a confident and well-organized way so we can move those patients forward? The question I would ask to you, KC, is if we do all that, are we still going to hit a stone wall when we try to find a behavioral health bed for them and they’re going to end up spending 58 hours in the ER anyway?
That’s part of the long-term solutions that have to take place is we need more behavioral health resources to places to do these patients. A lot of my work has been around the front end of when patients come in because there are a lot of inefficiencies. One of the things that prompted us to even look for something like ABOUT was when you think about the crisis space, the whole transfer process from getting the emergency room, assessing a patient, and getting you to go to inpatient. Doing the bed search process is an archaic process. The technology we’re using is a fax machine.
This process of calling multiple sites, waiting for people to review things, all the inefficiencies in that process, not having a central location that shows the history and shows where all the patients are, who’s accepting where and creates that space where people can see what’s happening, that’s a huge deficit all across the country. I do think that even if we get better at the emergency room, you’re still going to run into where patients are going to be waiting on behavioral health beds and some of the innovations that need to take place are taking place.
Part of the issue is thinking of how we get patients to go somewhere else. When you go to the emergency room because there are certain things that have to happen, there are going to be things that cause delays. If we were able to have more crisis stabilization units and have patients go there as opposed to the emergency room, will we see better outcomes? Could we see patients not going to inpatient units and being able to stabilize and being sent home?
When I talk about healthcare executives, I encourage them to go and interact with their local community mental health center and advocate to say, “Let’s partner and develop a crisis stabilization unit.” If you look, there’s been a lot of work done in this in Arizona. There is a lot of success in reducing emergency room crowding behavioral health patients by having a successful crisis stabilization unit. It takes that commitment from community mental health centers, state advocacy, and then also having physical health partners to say, “Let’s do this.”
You brought up some great examples. The work that we’re doing here with giving the crisis managers that same capability that for years we’ve given case managers to cast a broad net electronically and broadcast the need of that particular mental health patient in a safe HIPAA-compliant manner to multiple sites all at the same time so they can evaluate it. It’s just like you talked about with the pandemic. You had a patient that was sitting in a rural ER that needed to go to another hospital and the transfer center or the hospital they called said, “Our hospital is full, but right down the street they had another hospital that was only 50% full.” They didn’t even know about it or they didn’t have the time to call that one too.
What a great capability to give to crisis counselors and managers so they aren’t picking up the phone and calling all of these places individually. We can do this in mass. You brought up the State of Arizona who did a fantastic and stellar job as a state rallying leadership and various hospital systems to coordinate the need during the pandemic. It’s great that they’re continuing that.
As a matter of fact, I remember talking to the director of the Department of Health there of the state that they have a focus on behavioral health to give that same coordinated capability across the state. I would advocate that across our entire country. We could move this process forward and not have patients boarding if we just had greater visibility and the ability to place these patients in that fashion like you’re doing in HealthSource. Great ideas.
There’s a lot of anecdotal data across the country about why behavioral health patients are stuck. One of the things that we’re most excited about with the ABOUT product and why we’re doing this is that we are going to be generating so much data around this process so that we can use this to advocate at the state level to say, “Here’s what’s going to make the most impact. Is it more beds? Is it a different type of bed? Do we need more geriatric beds? Do we need more child-adolescent beds? Where are those pain points?” Being able to give a comprehensive view to the decision-makers is going to be critical for changing this paradigm.
Until we’re able to make some of those changes, some of which are a little bit farther down the road. I want to come back to a couple of ideas that I implemented when I was the CEO of a large hospital that seem to work well. If you have people that are boarding for inordinate amounts of time, what are some recommendations that you would have about how to provide care to those people that are in the emergency room potentially for 30, 40, or 50 hours to try to lessen the impact both to them and the functioning of the emergency room department to make it a little bit easier for the patient and the folks treating them?
One of the things I was struck by when I first started working with our crisis teams in Pennsylvania was one of my crisis direct managers told me, “If we could just get home meds prescribed as patients while they’re in the emergency room, we might see a different outcome.” That’s a complicated issue because oftentimes these patients that are coming in are on medications that should be only monitored and prescribed by a psychiatrist.
Darin brought it up earlier that you have these emergency room physicians that say, “This is not what I signed up for.” How can we better support emergency room physicians? Is it through teleconsult? There’s been a lot of work in North Carolina to have psychiatric consults available, but if you have a patient who’s on these psychotropic medications, going to take them off of it while they’re in the emergency room because we don’t feel comfortable prescribing or asking for bad results.
Doing some of those kinds of things that make sure that those patients have home meds, maybe they stop taking them and getting them back on them might reduce their need for inpatient state in the emergency room care. When you think about emergency room care for reporting patients, we have a one-track mind. We assess them. They did inpatient and we’re going to go in that direction. To continually reassess them, if a patient sits for three days and they’re getting home meds and they’re being interacted with caring healthcare providers, sometimes that reduces the need for crisis and they might be able to be discharged with a safety plan.
That’s scary for a lot of our emergency room physicians to jump out and say, “We’re going to let this person go,” because when they presented, they might have been super scary. However, get more behavioral health resources in the emergency room, more social workers, advanced practitioners, and psychiatry. I recognize I say that and there’s a shortage of all those resources.
Let me ask you a question with respect to that. Do you find that in most emergency departments, and Chuck, you probably have experienced this too because of your administrative background, that it’s a fairly consistent number of people that they’re seeing? The reason why I ask this is when you think about streamlining flow in something like an operating room and dedicating a particular suite to a particular type of procedure or level of care of a patient, that laminate flow of being able to have that dedicated resource.
You can only do that if you’ve got that consistent number of patients that need that resource. Do you find that as you look at emergency departments? Is it typical that they’re seeing the same number of patients on a daily basis where they can predict that and then dedicate a resource or shift resources to addressing that particular need?
I’ve done a lot of data. It is the name of the game. When we go back and look, it’s amazing to me how consistent our behavioral health patients are. It doesn’t always feel like that. I always joke when we have new staff that when we do crisis work, there’s sometimes when we’re sitting around twiddling our thumbs, then the next minute seems like somebody pulled up a bus to the emergency room and dropped all the behavioral health patients off at the same time.
When we looked at doing this work in the emergency room in Lebanon, there was very rarely a time when there weren’t people there. You talk about the volume of people showing up might change, but if they’re boarding, I would argue there’s probably always at least 1 or 2 behavioral health patients in most emergency rooms. When you talk about rural health, that’s where it’s a little bit more difficult because you’re talking about a lot more hit-and-miss. When you look, the data is consistent. Over the summer we tend to see. When the weather’s better you see. There are seasonal trends in behavioral health as well. Looking at those things and recognizing that is important.
There are seasonal trends in behavioral health. Looking at those things and recognizing that is important. Click To TweetOne of the reasons that we did some of the things that we did, I was in a large hospital in the South and there was a pretty significant homeless population. There was no question that we were also the only level-one trauma center in Northeast Georgia. We were only an hour outside of Atlanta, but we were at the trauma center. We were the place where the police always knew that they could come because nobody was going to turn anybody away. We were fortunate because we had an outpatient mental or behavioral health center in the community. We brought them to the table along with the police and several other mental health providers in the area.
One of the things that we did was we ended up leasing some mental health beds from a provider. There was some risk associated with that. If you lease beds, whether they’re somebody in them or not, you’re going to pay for them. Knowing that we potentially had some beds available for the sickest patients was a huge upside and worked well. We had a lot of folks that were in jail with mental health situations.
We worked with the county jail and the police to have a nurse practitioner at the jail who could at least do the initial assessment and cut through a lot of the stuff that you were talking about earlier that’s filling up the emergency room and causing people to sit there forever and ever. Most of the time, at least we knew that the person was medically stable. We took a floor right above the emergency room that was not in use for any patient care and turned it into a patient care area which is where we triaged all of the mental health patients.
We had some nurse practitioners up there who were at least able to care for them until we were able to find some placement. There are some things that don’t cost a lot of money that goes under the rubric of bringing all of the community resources together into a room and figuring out with your partners how to work together to make this better because it can’t just be the emergency room. I don’t think that’s the answer. It can’t be us waiting to build some new inpatient beds because that’s going to be a long time of waiting.
For physical health providers or acute care hospitals, because the long-term solution is out there, we’re going to have to adapt and do things. As opposed to looking and saying, “That’s a behavioral health problem. We’ll let somebody else deal with it.” Working collaboratively with those community behavioral health providers and advocating on their behalf. If you look, there are a lot of things happening across the country.
There’s a lot more investment happening in behavioral health. There are going to be some positive things coming out of it. For instance, across the country, you’re starting to see certified community behavioral health centers that are getting certified. Some states are adopting this. This is the new model. As part of the metrics for CCBHCs, it is the reduction of emergency room stays and the reduction of needing higher care.
You’re going to have a lot of providers who are going to be very interested to say, “How do we work without an emergency room to keep people from going to the emergency room to stabilize them in the community?” There are going to be a lot of innovations in that space, but if our representatives are only hearing from behavioral health to say, “We need more resources,” sometimes can fall on deaf ears. If you have behavioral health, law enforcement, and acute care saying, “This is not working. How do we make this better? What are those things that we can do?” You will get traction at those levels. You can see that. We brought up Arizona as a great example and I’m hoping that through this partnership with ABOUT a lot of stuff. We’re doing that we put Kansas back on the map as a state that’s innovating.
You look at those states where you’ve had that collective group of behavioral health, mental health, and law enforcement in the state working together and you’re saying amazing things. They’re taking care of people better. They’re freeing up resources and using the right person at the right time to provide care to that patient. That’s what’s going to be needed and creating innovation in something that has not been innovated in a long time. Using things like ABOUT to create that network to say, “When we do have this or when the system has broke down, we are going to get people to care as quickly as possible and provide the resources that they need to get them their quickest.”
Darin, I don’t know if you had any last questions that you wanted to ask KC. KC, do you have anything that you wanted to finish with? I would like you to paint a best practice plan that you either can envision through using technology or that you’ve seen work or technology has been used because I don’t think we utilize technology. You’ve mentioned ABOUT technology here several times. In the best of all worlds, what would the technology do to assist in this entire problem? What do you want the technology to do?
There are always going to be things that take up time in this process. There are always going to be things where you have to have a human that sits down, assesses another human and then makes decisions on that. All the other things, the bed search and transfer process, there are many redundancies that if we were able to create a document that started the emergency room and followed that patient all the way up to inpatient to where they didn’t have to get asked the same questions 15 to 20 different times would be amazing.
That’s what we’re trying to accomplish. We are going to use ABOUT, not just for the closed-loop referral system, which is going to be amazing, but we’re using it to assess patients and then send that assessment that will follow that patient. When they get accepted by the emergency room, they’ll have a comprehensive picture that they can use. Hopefully, they won’t have to ask the same questions. They can use our information to populate their information or even when they go to the court system if they get their rights taken away to be an involuntary place for inpatients. Having all that stuff follow them I think is critical.
Also, identifying patients quicker. Being able to identify a patient that’s likely going to need inpatient when they walk through the emergency room door is not a difficult thing. There’s some nuance to it, but it is capable. If we start working from the time they hit the door to find placement for them and we go through the process, then they’re going to be spending less time in the emergency room. Those things are capable and it requires thinking differently about how we invest in the technology to make sure that we’re getting patients to the right places at the right time and as quickly as possible.
KC, this has been a great conversation. What we always try to do is try to give some very practical and doable ideas to our audience. We’ve had a number of those things discussed. Thanks a lot for your expertise and it’s been great talking to you.
Thank you so much for having me. I appreciate the opportunity.
Darin, we had a great conversation with KC Johnson and talked a lot about the behavioral health crisis. The thing that I got out of it, which I think both of us knew was that we’re not going to fix this problem that we have in this country in the emergency room. We’ve got to come up with a lot of innovative thought processes in the way that we approach behavioral health patients when they hit the emergency room door. We heard a lot of suggestions about triaging them to a separate unit, having the behavioral health consult called right after the first step of the process and not waiting to medically clear a patient which can take 3 or 4 hours. We talked about bringing a lot of the community resources together to come up with some partnership solutions.
We talked about using technology like the ABOUT technology in order to understand the transfer process better and be able to see where beds are available so that we don’t waste time trying to find a bed placement for the patient. We also talked about some of the best practices and caring for the patient in that chaotic emergency room. Things that are as practical as making sure that we figure out a way to know what meds they’ve been on and making sure they continue those meds during the stay. Our audience will get a lot of practical information out of what KC had to say and maybe be able to implement some of his ideas. What did you think, Darin?
KC with his experience, not only with HealthSource and what he’s doing but looking back through his career and what he’s done with other organizations. His approach as not only a consultant in this industry but in the trenches that their organization gets in there and is doing the work, seeing how they’re creating a scalable model that they’re applying within their own organization to the hospitals and healthcare systems that they consult with even on a state level with the state of Kansas.
Those are all areas that our readers should and would be interested in to bring back to their own organizations for all the reasons you mentioned. Applying many of these techniques that we’ve seen in other areas within our own healthcare industry, being able to cast a broader net to get these mental health patients who are in such desperate need to get their issues addressed as well and being able to do it in a faster time period. We’ve just scratched the surface in this conversation with KC. It’s a great starting point. I look forward to many more conversations with him and his organization.
For our audience, we’re going to continue over the next number of episodes speaking with the actual operators, like yourselves, the people that are in the trenches trying to figure out solutions to these difficult problems. Certainly, we’d all agree that behavioral health is one of the most challenging issues that we have. Please continue reading and we’ll continue to try to bring people on who can offer some real practical, pragmatic solutions that hopefully you can apply in your organization. Thanks for reading. We’ll look forward to seeing you at the next episode.
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About Kenneth (K.C.) Johnson
K.C. Johnson is an accomplished business executive and entrepreneur with a proven track record of success in the healthcare industry. He currently serves as the Chief Executive Officer of Healthsource Integrated Solutions, a shared service organization in Kansas. He brings over 20 years of experience in healthcare operations and management to his role as CEO.
Prior to joining Healthsource, K.C. served as the Service Line Director for Behavioral Health Access and Crisis Intervention services at WellSpan Health, a large integrated health system based in York PA. At WellSpan, he was responsible for developing and implementing strategic initiatives to improve access and the delivery of patient care.
Under Mr. Johnson’s leadership, Healthsource has experienced tremendous growth and success. He has led the company through a period of rapid expansion, launching new products and services and expanding into new markets. He has also been instrumental in developing strategic partnerships with key industry players, positioning Healthsource as a leader in the Crisis Intervention Industry.
Mr. Johnson will share his perspective and insights on this important theme and topic, providing practical suggestions that can be applied immediately.
K.C. Johnson holds a bachelor’s degree in Sociology from East Texas Baptist University, a master’s degree in Family Psychology from Hardin-Simmons University, and a master’s degree in business administration from Lebanon Valley College. He is a Fellow of the American College of Healthcare Executives and a United States Air Force veteran.
