Expedited Psychiatric Inpatient Admissions (EPIA) Policy

Each day residents of the Commonwealth in need of inpatient psychiatric hospitalization wait in hospital emergency departments (EDs) for extended periods of time, known as ED boarding. For those waiting for a bed in psychiatric hospital facilities, if there is not a plan in place for them after 2 days in the ED, there need to be additional steps to facilitate their placement. The Executive Office of Health and Human Services (EOHHS) is committed to addressing ED boarding in the Commonwealth and spent over 18 months understanding the problem, meeting with key stakeholders, and developing solutions.

EPIA Task Force

At the direction of EOHHS Secretary Marylou Sudders, the Department of Mental Health (DMH), together with Office of MassHealth (MassHealth) and the Department of Public Health (DPH), in partnership with the Division of Insurance (DOI), convened a task force to develop expedited psychiatric inpatient admission interventions available for all individuals boarding in EDs for extended periods of time. The task force membership includes the government conveners, insurance carriers, psychiatric and medical hospital providers, hospital and carrier trade associations, professional associations and state agency representatives. This group has worked intensively during the last several months to develop a multi-pronged approach to ensuring these individuals move expediently into the inpatient level of care they require.

The results of this collaborative process are:

• An Expedited Psychiatric Inpatient Admission Policy, setting clear steps and responsibility for escalating cases where placement has not been achieved in a reasonable period of time to senior clinical leadership at insurance carriers, inpatient psychiatric units, and ultimately to DMH, with the goal of identifying and resolving barriers to admission.
• A Division of Insurance Bulletin, issued jointly by DOI, DMH and DPH, establishing the expectation that insurance carriers subject to DOI regulations will have adequate networks of inpatient psychiatric facilities, and will have the capacity to help facilitate admission of difficult-to-place patients seven days a week.
• Revised DMH regulations that establish the principle that DMH licensure is guided by the needs of the Commonwealth to have the range of inpatient resources available to address the clinical requirements of its citizens, and delineating DMH’s role in assuring that the facilities that it licenses are fulfilling their responsibilities to meet this need under their license.

EPIA Protocols

The protocol development began with the principles and processes established by a Payer-Provider group led by the Massachusetts Health & Hospital Association (MHA) as part of EOHHS’ ED Boarding initiative. Using that work as a starting point, the task force has developed protocols for expediting placement of individuals boarding in the ED, including defining roles and responsibilities at each escalation point in the process.

The protocols developed are outlined below. MHA has committed to developing and maintaining a website with relevant materials and contact information for ongoing training of both providers and payers. Each Managed Care Insurer/Payer (Insurance Carrier) has provided a specific point of contact for these protocols.

In order for these protocols to apply, an individual must be assessed by an Emergency Department or Emergency Services Provider (ED/ESP) and determined to require hospital level of care.

• Any authorization (for inpatient hospital level of care, for 1:1 staffing or other specific needs) is provided as soon as the need is known. 
• If at any time during this process, a placement is identified but will require a wait (for example, a planned discharge in a day or two), these escalation protocols will not be activated, as long as that placement is appropriate and all parties are in agreement and the individual can safely wait in the ED.
• There will be continuing conversation between the ED/ESP and the Insurance Carrier throughout this process to ensure that the most current information is available and that there is no duplication of effort in the placement work.
• State agencies that have the individual as a client can be engaged at any point in the protocols.
• If the constraint to finding a hospital bed is an individual or family preference, these protocols will not be activated, and the ED/ESP will continue to work on acceptance of other placements.
• If the request for inpatient placement is withdrawn, these protocols no longer apply.

The Escalation Steps

Step 1: If a placement has not been identified by 24 hours from a patient’s arrival to an ED

• The ED/ESP will notify the appropriate person at the Insurance Carrier or other party responsible for administering the patient’s health coverage that one of their members is in the ED at the 24 hour mark, if that carrier has not already been contacted. (There is work being done among stakeholders to make this an automated process). The Insurance Carrier will use its internal care management processes to determine if there is useful information that can be provided to the ED/ESP to assist in placement. 3 January 10, 2018
• At any time, the ED/ESP may solicit the help of any State Agency involved with the individual (DCF, DDS, DMH, DYS) to seek information, care management, treatment plans, or special services to aid in successful placement.
• At any time after the decision is made to admit the individual to a psychiatric hospital and it is clear that a placement will not be identified by 48 hours, the ED or ESP can reach out to the Insurance Carrier with a Request for Assistance.

Step 2: If a placement has not been identified by 48 hours from a patient’s arrival to an ED

• The ED/ESP will make a formal Request for Assistance to the Insurance Carrier.
• Within two hours of the submission of a Request for Assistance by an ED/ESP during normal business hours, an employee of the Insurance Carrier will acknowledge receipt of the request and initiate a process to facilitate the admission of the individual into an appropriate hospital. When a Request for Assistance is made outside of normal business hours (e.g. on weekends or holidays), the acknowledgment will be made no later than the morning of the next calendar day after the request is made.
• The Request for Assistance will provide the Insurance Carrier with clinical information about the individual, barriers to admission, evidence of the bed searches to date, and a summary of responses from hospitals who have denied admission to the individual. For example:

Patient Demographics	Name DOB Health Plan Member ID Address/Contact Information
ED Presentation & BH Diagnosis	ED Facility Date/Time of Admission Length of Time Boarding Presenting problems/symptoms Diagnosis/co-morbid conditions
Placement/Boarding	Level of care needed Reason for Boarding
If Information has changed since a previous contact was made to the health plan	Presenting problems & Symptoms Co-occurring complexity Additional Patient Needs Type of placement required
Facilities/units already contacted	Name of facility and reason, circumstance, or barrier provided as to why they are unable to accept patient for admission Other Resources needed to admit the patient if available to the ED/ESP; if barrier is lack of beds, when discharges are anticipated
Other Patient Information	Relevant patient history with a facility Patient, Parent, Family preference for Placement

• The Insurance Carrier will work closely with the ED/ESP to avoid redundancy in bed searches and to determine which hospital(s) is the most appropriate facility to meet the needs of this member at this time.
  • The Insurance Carrier will determine, authorize, and pay for required supports or resources not previously authorized, when such supports or resources are determined to be needed by the hospital to allow for admission.
  • The Insurance Carrier will seek to mitigate any authorization issues that are presenting barriers to a successful placement.
  • If the specific hospital(s) deemed most appropriate by the Insurance Carrier to serve this individual does not have an immediate bed but will have one within the next 24-48 hours, the Insurance Carrier will seek to have the hospital agree to prioritize the placement of the individual. If no innetwork bed is anticipated to be available within a reasonable period of time, but no later than 24 hours from request for assistance, the Insurance Carrier will seek placement in appropriate out-ofnetwork facilities (taking into account services required by the individual, geography, etc.).
  • The Insurance Carrier will engage the clinical and administrative leadership of the hospitals deemed most appropriate for the individual awaiting placement.
  • The Insurance Carrier will remain actively engaged and seek to obtain admission of the individual until a placement has been secured.
  • Once the Insurance Carrier has exhausted its network and appropriate out of network options, or after another 48 hours has elapsed and the individual still has not secured an inpatient placement, the Insurance Carrier will notify DMH that the matter is being escalated for its involvement.
  • The Insurance Carrier is responsible for informing hospitals deemed appropriate to admit the individual that the process is being escalated to DMH.

Step 3: If a placement has not been identified by 96 hours from a patient's arrival to an ED

• The Insurance Carrier (or ED/ESP) requests assistance from DMH by 96 hours (end of fourth/beginning of fifth day in the ED).
• The Insurance Carrier will contact DMH by submitting an online referral request using a secure web site to provide notification that its member requiring hospital level of care has still not been placed.
  • The Deputy Commissioner of CPS or designee will serve as the point person within DMH to ensure placement.
  • The Insurance Carrier will designate a senior clinical administrator to serve as point person to communicate with DMH.
  • The internal DMH team will work with Insurance Carrier and Providers to determine next steps to ensure that hospital placement for the individual is accomplished.
• The Insurance Carrier will provide DMH with the result of its due diligence in seeking a placement with sufficient detail for DMH to immediately initiate a clinical conversation with the Insurance Carrier and hospital(s) that have a bed available and are deemed appropriately resourced to meet the needs of the ED Boarding individual.
  • DMH Referral Tool will be used by the Insurance Carrier to engage DMH.
  • Designated Insurance Carrier Clinical Administrator engages the Deputy Commissioner of CPS or designee.
• If the barrier to admission is clinically based, DMH will convene a Provider, Insurance Carrier and DMH “doc to doc to doc” conference call to understand and resolve these barriers.
• If the barrier to admission requires other State Agencies to resolve such barriers, DMH will convene a conference call with the appropriate State Agency representatives, Providers, Insurance Carriers and other Payers, as well as others needed to resolve such issues.
• If the barrier concerns payment, a discussion will be facilitated with the Insurance Carrier and MassHealth or DOI as appropriate. MassHealth and DOI will address network adequacy and payment issues with the Insurance Carrier.
• Data will be collected about these interventions and will be reviewed on a regular basis when DMH Licensing conducts regulated surveys for continuing licensure and as indicated.

Individuals who are uninsured or have a carrier not regulated by the Commonwealth (DOI)

No individual boarding in an ED waiting placement in a psychiatric hospital will wait more than 96 hours before DMH has been notified, regardless of whether the individual is uninsured or has coverage not regulated by DOI. In the circumstances that the individual boarding in the ED: a) does not have insurance and is not eligible for MassHealth benefits, b) is covered under a self-funded ERISA Plan, c) is covered solely by Medicare, or d) has coverage through an out-of-state insurance carrier, the ED/ESP will continue its efforts to locate an appropriate placement and to engage the identified payer (if there is one) for assistance as provided above. If these efforts are unsuccessful, the ED/ESP may advance its Request for Assistance to DMH after the initial 96 hour period. It is expected that the ED/ESP and any Insurance Carrier reaching out to DMH continue to play an active role in the placement of the individual.

Specifically: 

• Individual is totally uninsured: a rapid assessment by the ED/ESP will determine whether the individual is Medicaid eligible and if they are, MassHealth will include them in their Protocol. If not MassHealth eligible, the ED/ESP will call DMH at the 96 hour of boarding if a bed still has not been found for the individual.
• Self-funded ERISA Plan: if the individual requires hospital level of care and is still boarding in the ED at 48 hours, the ED/ESP will contact the ERISA Plan Administrator with a Request for Assistance. If the Plan does not engage, the ED/ESP will continue its efforts to secure a placement and will contact DMH after another 48 hours and will also provide DMH the contact(s) for the Plan.
• Medicare Only: ED/ESP will continue its normal bed search procedures and notify DMH for assistance after 96 hours if placement efforts are unsuccessful.
• Out-of-state commercial or Medicaid Insurance Carrier: If a covered member of these out-of-state Insurance Carriers has not been placed in a hospital bed by 48 hours, the ED/ESP will make contact with the Insurance Carrier with a Request for Assistance. If the Insurance Carrier does not engage, the ED/ESP will continue its efforts to secure a placement and contact DMH after 96 hours if placement efforts are unsuccessful.

Summary of Protocols

Member Insurance	Proposed Process
MassHealth Involved
*MassHealth managed Care	ED/ESP Request for Assistance to Insurance Carrier by 48 hours Insurance Carrier outreaches to DMH 48 hours later
MassHealth non-managed care (FFS, HSN, duals)	ED/ESP Request for Assistance to a TBD party at MassHealth by 48 hours that TBD party to outreach to DMH 48 hours later
Commercial Coverage
*Insurance carrier regulated by DOI	ED/ESP Request for Assistance to Insurance Carrier by 48 hours   Insurance Carrier outreaches to DMH 48 hours later
Administer for self-funded ERISA Plans not regulated by DOI OR Out of state insurance carrier	ED/ESP Request for Assistance to appropriate Administrator or Carrier by 48 hours  If Insurance Carrier will not engage, ED/ESP continues to search for a bed and contacts DMH 48 hours later, including Insurance Carrier contact information
Other
Medicare ONLY OR  Uninsured	ED/ESP continues to search for a bed and notifies Uninsured DMH at 96 hours

*Insurance represents those in the standard process outlined.

Additional Resources

Expedited Psychiatric Inpatient Admissions Protocol 2.0