Reducing Behavioral Crisis Emergency Room Visits through a Novel Care Model: Behavioral & Developmental Neuropsychiatry (BDNP) Care Continuum

Background: The Behavioral & Developmental Neuropsychiatry (BDNP) care continuum group at Cincinnati Children's Hospital in the Division of Psychiatry frequently serves patients with ASD and significant irritability marked by physical aggression, self-injury, and severe tantrums. High patient acuity and limited outpatient care resources contribute to high emergency room (ER) visit rates when in crisis in this population. The BDNP care continuum has 3 mechanisms to reduce ER visits for behavioral crises in the highest acuity patients: 1) Outpatient nurse care management; 2) Mental Health Specialist support in outpatient clinic to enhance outpatient visit safety thus promoting adherence to outpatient care; 3) An across the continuum effort to direct admit patients (bypassing an ER visit) to our BDNP inpatient unit when admission is deemed necessary.

Objectives: The key objective of this study was to assess the rates of ER visits for behavior pre- and post-enhanced continuum care efforts in the first 30 patients served in our ASD/MI care continuum. The specific aim was to determine if enhanced outpatient management was associated with reduced ER visit rates. The key secondary aimwas to determine any potential cost savings associated with findings from our primary aim.

Methods: We gathered data from the first 30 patients with ASD/MI enrolled in our enhanced BDNP care continuum. Requirement for enrollment in this enhanced level of care included a history of severe self-injury and/or aggression and a clinical global impressions severity (CGI-S) score of 5 “very ill” or greater. This data review project was approved by the CCHMC IRB. Data was extracted from EPIC charting looking at ER visits for behavioral reasons for each of the first 30 patients enrolled in the enhanced BDNP care continuum. Our primary outcome is a comparison of the number of ER visits for behavioral reasons on an annualized basis prior to and after the implementation of enhanced BDNP care for each patient assessed.

Results: Each patient showed a reduction in ER visits per year due to behavioral crisis. All patients met diagnostic criteria for intellectual disability, autism spectrum disorder, and intermittent explosive disorder. A statistically significant mean reduction in annualized ER visits for behavioral crisis was noted (See Figure 1; change from a mean 1.7 +/- 0.9 ER visits per year pre-intervention versus 0.3 +/- 0.4 visits per year post-intervention; p<0.0001). For this patient cohort followed, an estimate ER visit cost savings of $92,405 per year was calculated.

Conclusions: This report is consistent with reduced ER visits for behavioral concerns post enhanced BDNP care initiation. Future Directions include, but are not limited to, the following: 1) Assess for potential patient and family quality of life change with initiation of this treatment approach; 2) Assess for injury reduction associated with enhanced care initiation; 3) Assess the ability to expand and develop the model to meet a growing need for such services. We hope to expand this work to a broader group of patients in the future in need of these services.