Divert Behavioral Healthcare from The Emergency Department

Clients are sounding the alarm as emergency room visits skyrocket among kids in crisis. Behavioral health patients who are deemed a risk to themselves or others are often boarded for days or weeks, waiting for an inpatient bed that doesn’t exist or is occupied by another patient who has completed treatment but has nowhere else to go. The ripple effect is leading to longer stay lengths across the boards and even longer wait times for medical admissions in the ED.

The growing trend of integrating behavioral health treatment space in the ED is a short-term fix to meet surging demand, but it’s not a sustainable long-term solution to the underlying problem. Worse, it can perpetuate the trauma of behavioral health patients who end up there, diminishing their trust in the healthcare system and likelihood of seeking future care.

Health systems are striving to invest in both inpatient and outpatient behavioral health facilities to ensure every child receives the right care, in the right setting—before they end up in the ED. The most expensive care possible is when a patient is in crisis.

Increase Access to Community Care

We know from experience that the solutions inside the hospital are complex, but the solutions outside the hospital are quite simple. Designing outpatient behavioral health facilities is not difficult, it just needs to be done right. If health systems can extend outpatient facilities into the communities where patients live, then care is easily accessible when and where they need it.

As architects and designers, we can design the facilities to help families navigate the process, normalize their experience, support everyday life, provide resources and education, and foster a sense of community, dignity, hope, and belonging. But healthcare can’t solve the problem alone. Let’s also build in opportunities for partnerships with primary care providers, schools, and community center programs to approach the problem holistically.

Bolster the Missing Middle

Many clients are struggling to build or staff facilities in what we call the missing middle:

• Intensive Outpatient/Partial Hospitalization Programs
• Behavioral Health Urgent Care
• 23-Hour Crisis Intervention Centers

Often this is due to state and federal funding that excludes pediatrics, or limited Medicaid reimbursement, or restrictive requirements for bed licensing. But these facilities, whether integrated into expanding EDs or standalone outpatient facilities, are most needed right now to stabilize patients in crisis or on the verge of crisis and to divert them from the ED.

At the same time, clinical care is evolving faster than building codes. This has left a regulatory gap between 23+ Hour Crisis Receiving Centers, which can help divert patients from inpatient care, and residential treatment facilities where patients can transition after inpatient treatment.

Clients are forced to consider the maximum acuity of care they can provide in their outpatient facilities and the best ways to integrate high-acuity behavioral healthcare into their existing inpatient or emergency departments. The challenge is keeping behavioral health programs separate from other service lines and beds that don’t need to serve them. Architects and designers can inform future codes and policies that create new pathways for behavioral health and emerging models of care.

Build Intentionally 

From conference rooms to prep and recovery areas, repurposing existing spaces that are not designed for behavioral healthcare can have unintended consequences. They may not meet the needs of the program or workflows, or they may displace another program with vital needs. Non-clinical spaces may also have physical constraints.

While adaptive reuse is not always ideal, sometimes it’s the only space hospitals have and the need is too great to wait. In that case, let’s design it intentionally for behavioral health patients and providers while allowing for flexibility as needs change. In this context, flexibility is not about accommodating multiple uses—as with the ED, where spaces might serve dual functions for medical and behavioral treatment—but rather multiple acuities along the behavioral healthcare continuum. If all patients are safe in the space, all patients can be treated in the space.

Support & Sustain Staff

In any healthcare environment, care teams and staff need the right spaces and amenities to support an emotionally demanding job. Even more so in behavioral health facilities, the building layout itself can help them feel safer with the appropriate flows, visibility, and sightlines. Thoughtful allocation of spaces should support their workflow and acuity setting.

Provide respite spaces on-unit where staff can go after a patient encounter to decompress and care for themselves. When spaces are intentionally designed to set up staff for success, they will be reminded of what brought them to healthcare in the first place: to help people heal.