If you have an Emergency Department, you are in the Behavioral Health Business…..

1. If you have an Emergency Department, you are in theBehavioral Health Business….. August 2012

2. Retrieved from http://mediagallery.usatoday.com/G373

3. If you have an ED… • The question is: • How do you deal effectively with the need • in your community? 3

4. Number of people turning 65 each day Average Life Expectancy in 2010 Reduction in State and local behavioral health funding from 2009 to 2012 The percentage increase of patients presenting in your ED with behavioral health diagnosis from 2006 - 2009 Average wait for psychiatric patients in ED If you have an ED… Some Numbers: 10,000 78.3 $1.6B 20% 8 hours 4

5. Adults with comorbid behavioral health and medical conditions Patients discharged from community hospitals with a behavioral health primary diagnosis in 2009 Percentage of community hospitals with an organized inpatient behavioral health unit Reduction in hospital based units from 2008-2010 Number of hospitals with emergency departments If you have an ED… Some Numbers: 17% 2.0 M+ 27 10% 4,850 5

6. National Trends: Increased funding pressure on State and local behavioral health resources Hospital based behavioral health beds trending down Increased number of behavioral health emergencies Increased demand for treatment services for older adults with co-occurring physical conditions and behavioral health needs Integration of behavioral health and medical treatment Increased demand for consultation and liaison services Increased use of multi-disciplinary team approach Impact of National Health Reform If you have an ED… 6

7. Overall Trend: Utilization is increasing, capacity decreasing, impacting all aspects of your hospital and it is not going to get better anytime soon… If you have an ED… 7

8. Key issues facing most hospital ED’s: Lack of BH resources to triage and assess patients Lack of separate space to treat patients Lack of Psychiatrists to provide evaluations Lack of referral options Repeat customers Increased length of stay in ED If you have an ED… 8

9. Resulting Impact: Extended wait times for all patients in ED Increased diversion days or patients left without being seen BH patients disruptive to care for others Increased cost for security, sitters, etc. Med/Surg beds used for most severe patients Increased Re-admission rates Basically a throughput issue across the house… If you have an ED… 9

10. Options: Extend the continuum Behavioral Health ED/Access Center Observation beds Behavioral Health specific track If you have an ED… 10

11. What could a reduction in the BH patient ALOS in ED mean to a hospital…. Total ED Visits Total BH Visits ALOS Med patients ALOS BH patients Med/Surg admission rate ED patients LWBS If you have an ED… 65,350 5,500 4.5 hours 6.5 hours 17.0 % 1,200 11

12. What could a reduction in the BH patient ALOS in ED mean to a hospital…. Assume a ½ hr. reduction in BH ALOS Potential additional ED patients Med/Surg Admission Rate Additional Med/Surg admission Net Revenue Opportunity Net ED Revenue Opportunity If you have an ED… 550 17% 96 $900,000$350,000 12

13. Issues facing Hospital BH programs: Focused on Inpatient bed based services only Patient needs have moved from custodial to active treatment Many hospital programs not prepared for influx of chronic and forensic patients Safety issues (patient and staff) increasing ED the major source of patients Medicare beds being used as general adult Reimbursement for many patients reduced or non-existent High number of short-term stays with increasing re-admission rates If you have an ED… 13

14. Does every patient presenting in ED require an Inpatient stay? How many things are you doing in Med/Surg on the Outpatient side that were done on the Inpatient basis 10 years ago? If you have an ED… 14

15. Service Intensity More Less If you have an ED… Triage and Intake Psych ICU Unit Crisis Unit Med-Psych Unit Gero-Psych Unit Specialty Units General Adult Unit RTF Services 23-Hour Observation Transition Services PHP ½ Day PHP & SOP IOP Individual & Family Therapy Aftercare & Home Care ECT 15

16. Options? Continue as is… Outsource Behavioral Health Evaluations and Assessments to 3rd party… Close beds… Fix and expand current programming… If you have an ED… 16

17. Continue as is… Can the hospital afford losses and additional costs - Throughput issues - Sitter/Security costs - Program diminished performance Liability and safety issues for patients and staff issues Continued increase in re-admission rates If you have an ED… 17

18. Outsource Behavioral Health Assessments and Evaluations to 3rd party….. May address Doctor to Doctor evaluation faster Improves throughput for patients discharged to home May improve throughput to existing programs Does not improve disposition options. What do you do with the patient? If you have an ED… 18

19. Close beds Stop the immediate fiscal bleeding for an existing Inpatient unit Potentially replace with med/surg service with better return Reduce staff and patient safety issues on unit What do you now do with those patients showing up in the ED? If you have an ED… 19

20. Fix and expand current programming… Are the beds utilized under the best designation? Medicare Exempt Units (Distinct Part Unit) is reimbursed on a per diem vs. DRG Medicaid days in a Medicare Exempt Unit do not count towards DSH On average an increase of 1 Medicare ADC for a year should generate an additional $250,000 in net revenue for a Medicare Exempt Unit. If you have an ED… 20

21. Fix and expand current programming (continued) Are you meeting the needs within the community? Do you have an adequate and working continuum? Is your programming contemporary? Is the staff training and credentials contemporary? Do you have denial issues? Are your psychiatrists aligned with the hospital? Is your consultation coverage for the ED and Med/Surg units working? A detailed assessment of your programs is a way to get a handle on these issues! If you have an ED… 21

22. As with many throughput issues it could be a combination of these various options! If you have an ED… 22

23. In closing: Need for comprehensive behavioral health services increasing State and local resources reduction not likely to be reversed in near term Behavioral Health ED visits and ALOS increasing Hospitals are being left to address the issue and need a comprehensive strategy If you have an ED… 23

24. Contact Information: James J. Free Senior Vice President, Business Development Diamond Healthcare Corporation (800) 443-9346 jfree@diamondhealth.com If you have an ED… 24