Here’s the good news: Spending on much-needed behavioral and mental healthcare in the U.S. has increased more than 50 percent in the past decade, reaching $225 billion in 2019, according to an Open Minds Market Intelligence Report.
Today that figure is set to expand even more following this summer’s passage of a federal gun safety bill that includes $8.6 billion to support the buildout of certified community behavioral health clinics in all 50 states.
Now the bad news: Even as behavioral and mental health conditions have become better funded and less stigmatized, trips to the hospital for behavioral health emergencies are on the upswing.
Between 2007 and 2016, emergency department (ED) visits for behavioral health services in the U.S. increased from 6.6 percent to 10.9 percent, according to the article “Increasing Emergency Department Visits for Mental Health Conditions in the United States,” published in the Journal of Clinical Psychiatry.
Recent stressors like COVID-19, polarizing politics, and economic instability have made matters worse. It’s now estimated that one in seven people arriving at an ED is there for a behavioral health issue or underlying mental or substance-abuse condition.
Challenges to behavioral health care
Although behavioral health services have expanded, EDs are often the only option for patients experiencing acute behavioral crises such as profound psychosis, aggressive or agitated behavior, intoxication, and/or suicidal tendencies.
Unfortunately, many EDs lack appropriate treatment spaces for these patients. Most EDs either hold these patients for extended periods or transfer them to an inpatient bed—neither of which are ideal from an operational, financial, or treatment perspective.
Another challenge facing hospitals is that behavioral health visits to the ED are often less profitable than other medical emergencies and can actually result in financial losses. This is because behavioral health patients are commonly held in the ED for long periods without receiving billable treatment while also occupying beds that could be used for other patients.
A 2011 study, “The Impact of Psychiatric Patient Boarding in Emergency Departments” by Wake Forest University, found that behavioral health patients stayed in the ED an average of three times longer than traditional medical patients, resulting in 2.2 fewer bed turnovers and a financial loss of $2,264 per patient.
A more recent study, “Economic Evaluation of the Emergency Department After Implementation of an Emergency Psychiatric Assessment, Treatment, and Healing Unit” published in the journal Academic Emergency Medicine, found that 75 to 80 percent of behavioral health patients in the ED could have been discharged within 24 hours had they received prompt evaluation and treatment in a calming, therapeutic environment.
Defining a behavioral health crisis unit (BHCU)
Behavioral health crisis units (BHCUs) embedded within hospitals offer such an environment. These specialized, calming spaces accommodate the safe and efficient assessment and stabilization of behavioral health patients.
BHCUs complement the continuum of care for behavioral and mental health patients and support the “triple aim” of healthcare: enhancing the patient experience, improving population health, and reducing costs.
Another benefit to the BHCU model is that it provides a specialized space that can accommodate many behavioral health patients at once and allow for expedited and reimbursable treatment.
Approximately 100 BHCUs are currently in use in the U.S. The reason more haven’t been built is due, in part, to unfamiliarity with the facility type and the lack of planning and design standards.
Hoping to clear up both issues, the Facility Guidelines Institute (FGI) convened a topic group of healthcare designers and behavioral health experts (including this author) to identify best practices and establish BHCU planning and design guidance that others could use.
The topic group’s work resulted in the addition of minimum design requirements for BHCUs in the 2022 edition of FGI’s Guidelines for Design and Construction of Hospitals and Guidelines for Design and Construction of Outpatient Facilities.
Information of these standards also are now available in a newly released FGI white paper, “Design of Behavioral Health Crisis Units,” which offers valuable insights for both healthcare providers and designers looking to provide hospitals and patients with a better and more compassionate model of care.
This article discusses some key points from the white paper, including how to best introduce a BHCU into an existing facility so it aligns with other services and how to design and program spaces for effective treatment.
Space considerations for BHCUs
The FGI white paper offers a broad outline for planning and designing BHCUs, beginning with location. The Guidelines documents require that BHCUs be placed adjacent to—or in close proximity to—a hospital’s emergency department or freestanding emergency care facility.
Coupling the two departments allows for the sharing of clinical support services and spaces, including medical triage, equipment and supply storage, and support areas for staff and families.
At the core of the BHCU is a multiple-patient observation area often called a milieu. As opposed to individual patient rooms, which can feel like “cells” for many people experiencing a behavioral health crisis, the milieu gives patients room to move about to help reduce anxiety.
Patients in the milieu typically use recliners to rest or recuperate, and tables are available for small group conversation. A self-serve snack or nourishment area can further give patients a sense of control over their situation.
Patients also interact with clinicians in the milieu. To encourage this connection, the white paper authors recommend integrating nurses’ stations into this space rather than positioning them behind a separated “fishbowl” of protective glass, which can limit engagement and can foster patient distrust.
In addition to the milieu, BHCUs may include single-patient observation rooms and secure holding rooms for de-escalation in the rare instances where coercive interventions are needed. The FGI Guidelines documents require an intake room or area, an exam/treatment room, and a quiet room for respite. The total number of patient care areas will be determined and documented in the functional program developed by the healthcare organization and its planning and design team.
Design in these spaces should focus on calming the patient by including—where possible—natural light, views of nature via windows or wall art, and furnishings and building materials that mitigate noise.
A soothing interior design approach with comfortable furnishings, relaxing and muted colors , and dimmable artificial lighting that can reinforce circadian rhythms is also recommended.
Safety and circulation within a behavioral health unit
While the design and programming of BHCUs prioritize open and calming environments, the authors of the white paper also lay out several suggestions for making these spaces as safe and secure as possible.
These include tactical design and technology solutions—such as ligature-resistant products, electronic badging for staff, duress alarms, and surveillance cameras—as well as organizational approaches that include training staff on how to de-escalate patients exhibiting aggression.
When locating a BHCU near an ED, planners and administrators should analyze travel distances between any shared support spaces to confirm efficient travel time for BHCU staff.
Furthermore, circulation paths for behavioral health patients—particularly those in crisis—should be organized to avoid intersecting with spaces dedicated to support services, staff-only zones, or other diagnostic/clinical service areas serving a broader patient census. BHCUs with projected high volumes may also benefit from a dedicated exterior entrance near the ED entrance.
Next steps for mental health care
Previous FGI Guidelines editions included an option for a secure holding room in EDs and freestanding emergency facilities. To address increased patient numbers, the 2022 documents for hospitals and outpatient facilities include standards for additional behavioral health spaces in EDs, including flexible secure treatment rooms and behavioral and mental health treatment rooms.
Yet even these additional spaces may not be sufficient to deal with the growing number of patients requiring emergency behavioral health care.
One reason emergency behavioral health care hasn’t kept pace with demand is that hospitals and the authorities having jurisdiction that approve their construction have lacked a clear understanding of the unique needs of these patient types.
FGI’s BHCU white paper provides clarity and insight into the operational and care benefits of having a separate treatment space specifically designed for behavioral health care.
When to consider a BHCU
Hospitals wishing to improve their care of emergency behavioral health patients—while also improving their bottom line—should ask themselves the following questions:
- What type of emergency treatment spaces are we providing for emergency behavioral health patients?
- What is their average length of stay?
- What is their health outcome?
- What impact does the care and treatment of behavioral health patients have on our operations and finances?
If the answer to one or more of these questions leaves room for improvement, it could be time to explore the opportunities offered by a BHCU.
For more information on this subject, download the “Design of Behavioral Health Crisis Units” white paper at https://fgiguidelines.org/resources.
Virginia Pankey, AIA, EDAC, LEED AP, is principal and senior medical planner at HOK and served as the chair of FGI’s Behavioral Health Crisis Unit topic group. She can be reached at [email protected]