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This book is designed for everyone, from hospital administrators to patients. It contains information and perspectives relevant to readers who are industry professionals and to those looking to gain insights into improving care and operational standards of practice. After years of “fighting the good fight,” we have learned that addressing the need for change management and barriers to improvement must be done with finesse to ensure the longevity of these changes.


While the list of barriers may appear daunting, the cultural and historical barriers that impact you and your team need to be researched, clearly understood, and overcome in order to make real change.

Historical Barriers

Historically, inpatient psychiatric hospitalization was the standard, and often the only treatment option for patients requiring moderate to severe psychiatric care. The deinstitutionalization and reduced funding for inpatient psychiatric facilities that began in the 1960s in the United States had an impact on how providers were reimbursed and how the field of psychiatry evolved. Even in the last two decades, the number of inpatient psychiatric hospitals, number of inpatient psychiatric beds, and general hospitals with psychiatric care units has continued to drop (Halmer et al. 2015).

Fast-forward to today, and we see that most psychiatrists and therapists practice outpatient treatment rather than inpatient or emergency psychiatry. Due to this shifting trend, there are less trained psychiatrists and therapists interested in filling these much-needed positions. This creates a large pool of unmet needs for patients with behavioral health crises that are using the emergency departments (EDs) at increasing rates.

There has been direct cost-shifting from the inpatient psychiatric units to EDs. While there are some fee-for-service areas with plenty of beds, the incentive to admit, and long lengths of stay for patients, the majority of the country does not have this luxury. It is the “luck of the draw” for the patient—based on geography—that determines what kind of inpatient care is available.

The treatment of minors and adolescents should be an area of separate focus when expertise required is addressed, as should any measurement mechanism, as most minors seen in EDs for behavioral health crises are cared for by clinicians that do not have specialized child psychiatric training (Chun et al. 2015). We are also aware that the length of stay in EDs for minors requiring psychiatric care is longer than for minors with other medical issues, resulting in higher rates of inpatient admission (Case et al. 2011).

We have discussed metrics extensively in this book, but these metrics, thresholds, and benchmarks must also be based on community constraints. The ED psychiatric team must act as an outspoken advocate for their patients, and must move out of their comfort zone and push for increased resources for these vulnerable patients.

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