Effect of a Virtual Patient Navigation Program on Behavioral Health Admissions in the Emergency Department: A Randomized Clinical Trial

• Published in: JAMA network open 2020-01, Vol.3 (1), p.e1919954-e1919954
• Main Authors: Roberge, Jason, McWilliams, Andrew, Zhao, Jing, Anderson, William E, Hetherington, Timothy, Zazzaro, Christine, Hardin, Elisabeth, Barrett, Amy, Castro, Manuel, Balfour, Margaret E, Rachal, James, Krull, Constance, Sparks, Wayne
• Format: Article
• Language: English
• Subjects: Adult; Behavior Therapy - methods; Behavioral Medicine - methods; Clinical trials; Emergency Service, Hospital; Female; Humans; Intervention; Male; Mental Disorders - psychology; Mental Disorders - therapy; Middle Aged; North Carolina; Online Only; Original Investigation; Patient Admission - statistics & numerical data; Patients; Psychiatry; Self destructive behavior; Self-Management - education; Telemedicine; Telemedicine - organization & administration; Treatment Outcome; Young Adult
• ISSN: 2574-3805; 2574-3805
• DOI: 10.1001/jamanetworkopen.2019.19954

The number of patients presenting to emergency departments (EDs) for psychiatric care continues to increase. Psychiatrists often make a conservative recommendation to admit patients because robust outpatient services for close follow-up are lacking. To assess whether the availability of a 45-day behavioral health-virtual patient navigation program decreases hospitalization among patients presenting to the ED with a behavioral health crisis or need. This randomized clinical trial enrolled 637 patients who presented to 6 EDs spanning urban and suburban locations within a large integrated health care system in North Carolina from June 12, 2017, through February 14, 2018; patients were followed up for up to 45 days. Eligible patients were aged 18 years or older, with a behavioral health crisis and a completed telepsychiatric ED consultation. The availability of the behavioral health-virtual patient navigation intervention was randomly allocated to specific days (Monday through Friday from 7 am to 7 pm) so that, in a 2-week block, there were 5 intervention days and 5 usual care days; 323 patients presented on days when the program was offered, and 314 presented on usual care days. Data analysis was performed from March 7 through June 13, 2018, using an intention-to-treat approach. The behavioral health-virtual patient navigation program included video contact with a patient while in the ED and telephonic outreach 24 to 72 hours after discharge and then at least weekly for up to 45 days. The primary outcome was the conversion of an ED encounter to hospital admission. Secondary outcomes included 45-day follow-up encounters with a self-harm diagnosis and postdischarge acute care use. Among 637 participants, 358 (56.2%) were men, and the mean (SD) age was 39.7 (16.6) years. The conversion rates were 55.1% (178 of 323) in the intervention group vs 63.1% (198 of 314) in the usual care group (odds ratio, 0.74; 95% CI, 0.54-1.02; P = .06). The percentage of patient encounters with follow-up encounters having a self-harm diagnosis was significantly lower in the intervention group compared with the usual care group (36.8% [119 of 323] vs 45.5% [143 of 314]; P = .03). Although the primary result did not reach statistical significance, there is a strong signal of potential positive benefit in an area that lacks evidence, suggesting that there should be additional investment and inquiry into virtual behavioral health programs. ClinicalTrials.gov identifier: NCT03204643.