An Observational Study of Telemental Care Delivery and the Context for Involuntary Commitment for Mental Health Patients in a Group of Rural Emergency Departments

Background: Rates for all-cause U.S. emergency department (ED) visits to rural critical access hospitals (CAHs) have increased by 50% since 2005. During the same time period, total number of U.S. hospital admissions for a mental health (MH) crisis has increased by 12.2%, with rural counties demonstrating the largest suicide rate increases overall. Introduction: Increasing number of rural patients are reporting need for MH care in the region's four rural EDs. Characteristics of ED telemental health services were evaluated, including MH diagnostic category, voluntary vs. involuntary commitment (IC), forensic vs. nonforensic presentation, ED throughput, disposition, and payor reimbursement. Materials and Methods: Observational 2.5-year program evaluation of telemental health care delivery for children (n=114) and adults (n=417) who were evaluated by a rural ED physician and received an MH diagnosis. Participants (N=531) were treated by a licensed psychiatrist through telemental care delivery from September 2017 to April 2020. Results: Noncommitted ED MH patients (86%; n=455) were distributed across three major diagnostic groups: (1) depression, anxiety, or other mental illness (35%); (2) substance abuse (33%); or (3) suicide risk (32%), with 47% admitted inpatients (IPs), 47% referred outpatient (OPs), and 6% admitted to CAH. Fourteen percent (n=76/531) of ED MH patients were subsequently IC, with 67% of those assessed as needing IP care. Forty-nine percent (n=37) of IC patients presented in police custody. Most common diagnosis for IC patients was suicidal ideation/attempt (chi (2) [2, N=452]=12.884, p=0.002). Admitted patients experienced significantly longer length of stay than those with OP referral (p=0.001). Mean total payor reimbursements for ED MH care were significantly lower than actual ED costs (p<0.001). Discussion: Innovative approaches to telemental care for IC and non-IC patients need to be piloted and comparatively evaluated in rural CAHs. Conclusion: As the gateway to critically needed MH care, rural CAHs and public services pivotal to care access (e.g., law enforcement) need additional resources and support.