IntroductionMental health patients boarding for long hours, even days, in United States emergency departments (EDs) awaiting transfer for psychiatric services has become a considerable and widespread problem. Past studies have shown average boarding times ranging from 6.8 hours to 34 hours. Most proposed solutions to this issue have focused solely on increasing available inpatient psychiatric hospital beds, rather than considering alternative emergency care designs that could provide prompt access to treatment and might reduce the need for many hospitalizations. One suggested option has been the “regional dedicated emergency psychiatric facility,” which serves to evaluate and treat all mental health patients for a given area, and can accept direct transfers from other EDs. This study sought to assess the effects of a regional dedicated emergency psychiatric facility design known at the “Alameda Model” on boarding times and hospitalization rates for psychiatric patients in area EDs.MethodsOver a 30-day period beginning in January 2013, 5 community hospitals in Alameda County, California, tracked all ED patients on involuntary mental health holds to determine boarding time, defined as the difference between when they were deemed stable for psychiatric disposition and the time they were discharged from the ED for transfer to the regional psychiatric emergency service. Patients were also followed to determine the percentage admitted to inpatient psychiatric units after evaluation and treatment in the psychiatric emergency service.ResultsIn a total sample of 144 patients, the average boarding time was approximately 1 hour and 48 minutes. Only 24.8% were admitted for inpatient psychiatric hospitalization from the psychiatric emergency service.ConclusionThe results of this study indicate that the Alameda Model of transferring patients from general hospital EDs to a regional psychiatric emergency service reduced the length of boarding times for patients awaiting psychiatric care by over 80% versus comparable state ED averages. Additionally, the psychiatric emergency service can provide assessment and treatment that may stabilize over 75% of the crisis mental health population at this level of care, thus dramatically alleviating the demand for inpatient psychiatric beds. The improved, timely access to care, along with the savings from reduced boarding times and hospitalization costs, may well justify the costs of a regional psychiatric emergency service in appropriate systems.

BACKGROUND:The growing number of primary care physicians (PCPs) reducing their clinical work hours has raised concerns about meeting the future demand for services and fulfilling the continuity and access mandates for patient-centered care. However, the patient's experience of care with part-time physicians is relatively unknown, and may be mediated by continuity and access to care outcomes. OBJECTIVE: We aimed to examine the relationships between a physicians' clinical full-time equivalent (FTE), continuity of care, access to care, and patient satisfaction with the physician. DESIGN: We used a multi-level structural equation estimation, with continuity and access modeled as mediators, for a cross-section in 2010. PARTICIPANTS: The study included family medicine (n=104) and internal medicine (n=101) physicians in a multi-specialty group practice, along with their patient satisfaction survey responses (n=12,688). MAIN MEASURES: Physician level FTE, continuity of care received by patients, continuity of care provided by physician, and a Press Ganey patient satisfaction with the physician score, on a 0-100 % scale, were measured. Access to care was measured as days to the third nextavailable appointment. KEY RESULTS: Physician FTE was directly associated with better continuity of care received (0.172 % per FTE, p<0.001), better continuity of care provided (0.108 % per FTE, p<0.001), and better access to care (−0.033 days per FTE, p<0.01), but worse patient satisfaction scores (−0.080 % per FTE, p=0.03). The continuity of care provided was a significant mediator (0.016 % per FTE, p<0.01) of the relationship between FTE and patient satisfaction; but overall, reduced clinical work hours were associated with better patient satisfaction (−0.053 % per FTE, p=0.03). CONCLUSIONS: These results suggest that PCPs who choose to work fewer clinical hours may have worse continuity and access, but they may provide a better patient experience. Physician workforce planning should consider these care attributes when considering the role of parttime PCPs in practice redesign efforts and initiatives to meet the demand for primary care services.KEY WORDS: part-time work; continuity of care; access to care; patient satisfaction.

IntroductionThis is an observational study of emergency departments (ED) in California to identify factors related to the magnitude of ED utilization by patients with mental health needs.MethodsIn 2010, an online survey was administered to ED directors in California querying them about factors related to the evaluation, timeliness to appropriate psychiatric treatment, and disposition of patients presenting to EDs with psychiatric complaints.ResultsOne hundred twenty-three ED directors from 42 of California's 58 counties responded to the survey. The mean number of hours it took for psychiatric evaluations to be completed in the ED, from the time referral was placed to completed evaluation, was 5.97 hours (95% confidence interval [CI], 4.82–7.13). The average wait time for adult patients with a primary psychiatric diagnosis in the ED, once the decision to admit was made until placement into an inpatient psychiatric bed or transfer to an appropriate level of care, was 10.05 hours (95% CI, 8.69–11.52). The average wait time for pediatric patients with a primary psychiatric diagnosis was 12.97 hours (95% CI, 11.16–14.77). The most common reason reported for extended ED stays for this patient population was lack of inpatient psychiatric beds.ConclusionThe extraordinary wait times for patients with mental illness in the ED, as well as the lack of resources available to EDs for effectively treating and appropriately placing these patients, indicate the existence of a mental health system in California that prevents patients in acute need of psychiatric treatment from getting it at the right time, in the right place.

The EHR offers process of care measures which can augment patient-reported measures of patient-centeredness. Two of them are significantly associated with clinical outcomes. Future research should examine their association with additional outcomes.

Objective To describe three methodological challenges experienced in studying patients’ expressions of emotion in a sample of routine ambulatory medical visits, and the research and practice implications of these challenges. Methods Qualitative analysis of empathic cues in audio-taped and transcribed periodic health examinations of adult patients (n=322) in an integrated delivery system. The empathic and potential empathic opportunities methodology was used. Results Identifying emotional cues that constitute “empathic opportunities” is a complex task. Three types of ambiguities made this task particularly challenging: 1) presentations of emotional cues can be “fuzzy” and varied; 2) expressions of illness can be emotionally laden in the absence of explicit “emotion words”; and 3) empathic opportunities vary in length and intensity. Conclusion Interactional ambiguities pose a challenge to researchers attempting to document emotional cues with a binary coding scheme that indicates only whether an empathic opportunity is present or absent. Additional efforts to refine the methodological approach for studying empathy in medical interactions are needed. Practice Implications The challenges discussed likely represent the same types of situations physicians find themselves in when talking with patients. Highlighting these ambiguities may aid physicians in better recognizing and meeting the emotional needs of their patients.

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