Based on a promising pilot project, Virginia-based Sentara Health has rolled out a behavioral health navigator program in emergency departments across its system in Virginia and North Carolina. Tracey Izzard-Everett, Sentara’s vice president of behavioral health, recently spoke with Healthcare Innovation about creating this new role to guide patients through assessment, stabilization and follow-up coordination and connect them to community-based resources. 

Norfolk, Va.-based nonprofit Sentara operates 12 hospitals, over 300 sites of care, and serves more than 1.2 million members in Virginia and North Carolina.

Healthcare Innovation: Tracey, could you first talk about your role at Sentara?

Izzard-Everett: I’m helping to bring a strategy together where we can serve all of our behavioral health members in the community and health plan members in the most efficient way possible to make services that are seamless, easy to navigate, and that we're getting them the best outcomes possible.

HCI: Is that something that's traditionally been a challenge for health systems — that different aspects of behavioral healthcare are siloed and not well connected, so that it's not a smooth transition for patients?

Izzard-Everett: Exactly, that's where we drop the baton. And then we see our community members coming back into the emergency department because the community-based provider didn't didn't have access, or they didn't pick them up fast enough, or there wasn't a good connection. So then that community member comes back into the emergency department for another crisis. We really want to be that thread all the way through. If they're a health plan member and they're in crisis, we want to be able to divert them to the most appropriate level of care. If they do show up in the emergency department, we want to be able to direct them back to the most appropriate level of care, and then assure that they are receiving that care in an ongoing manner in a way that matches their needs.

HCI: If that is not happening, is it putting pressure on the emergency departments?

Izzard-Everett: That's exactly what was happening. We didn’t have access for the demand as it's increasing. Our community members already know that they can use emergency departments as their primary source of care. And if they don't know where to go in the community for an acute psychiatric crisis, for instance, they go right to the emergency department. Then our EDs back up with a lot of behavioral health crises. They're ready to set a broken bone or help with a heart attack, but they we're struggling with how to deal with that acute care behavioral health crisis. That’s part of where the navigator role came in. We're trying to relieve some of that pressure off the emergency department clinicians and doctors by helping to get the focus back on behavioral health.

HCI: Was this navigator program something Sentara officials saw somewhere else or developed on your own in-house?

Izzard-Everett: Certainly there are navigator programs out there, and it was a concept that was under way when I joined the organization. My team and I sat down and worked through what this would really look like. We had it spring from the health plan, because we were seeing the rapid re-admitters, and the acute care hospital said that would be incredibly helpful for them. We have two sets of navigators. We have navigators for our health plan that work with non-Sentara hospitals and facilities, and then we have behavioral health navigators that we have placed into the Sentara emergency departments.

HCI: We've written a lot about people in community health worker positions. Is that who this would be equivalent to or do they have specialized training or degrees in behavioral health?

Izzard-Everett: They have backgrounds in social work, psychology, counseling, or nursing, with behavioral health-specialized training. They are trained in motivational interviewing and trauma-informed care. They have a wealth of knowledge about community resources. That's really the key. They may or may not hold a license. Some of them do and some of them are in the process of becoming licensed. Part of their role is doing the quick assessment bedside counseling, but it is also be about the case management, and making sure that they know the community-based referral sources, and they're able to make that referral and get patients that follow-up appointment very quickly.

The other part of their role is to work alongside the clinicians and the ED docs to make sure that they're really understanding and triaging the acute care need the best way possible. The behavioral health navigator becomes a part of the care team in the emergency department. They meet with the patient, they meet with the family. And then get additional behavioral health resources engaged if they need a psychiatric assessment, or if we're looking at potential placement into a behavioral health unit, they'll help to start that process as well.

HCI: What's the approach to scaling this up across 12 hospitals? Did you do pilots in one or two and then roll it out across the whole organization?

Izzard-Everett: That's exactly what we did. We started with two and then we went to five, and now we are at 10. We have 10 behavioral health navigators on site, and they work Monday through Friday, first shift, and then in two of those hospitals, that behavioral health navigator also helps to remotely support two of our other hospitals. When we looked at the volume at those two hospitals, it didn’t necessarily support appointing a person, so that's why we went with 10.

HCI: What was the timeline for this? When did the initial pilots first start?

Izzard-Everett: We have been fully implemented for six months. And we had been piloting it at least the prior six months. So it's been about a year.

HCI: Is that long enough for you to expect to see positive impact on what the ED clinicians feel if they were experiencing bottlenecks before? Can you already measure the impact of having those navigators in place?

Izzard-Everett: We have been able to. Anecdotally, the emergency department clinicians and docs are asking us to hire a second shift because they are so helpful. We're in the second iteration of updating our dashboard. I can drill down in the data by provider type and payer type. What we've recognized is that when a behavioral health navigator is involved, we've seen a 21% reduction in the behavioral health unit readmission rate. If a navigator was involved and we linked them with community resources, they did not come back within 30 days for a behavioral health readmission. There also was a 16% reduction in the emergency department readmissions when a navigator is involved. So that tells us we're going in the right direction with getting them connected to community-based resources, and  they're not using the emergency department as their primary source of treatment as much.

HCI: You mentioned the ED docs are asking for a second shift. Any other plans for evolving this or measuring it going forward?

Izzard-Everett: I would say, stay tuned about where we go with it. It's a constant evolution. We also have what we call our PERS team. That stands for psychiatric emergency response services team. They are clinicians doing mental health assessments. They're the ones who are really determining whether or not a patient needs to be recommended for a behavioral health placement. They're doing the on-site behavioral health assessment, and they work hand in glove together as a team to decide whether the patient is going into placement or they are going to be released. It is a team-based approach. So we are looking at how we continue to evolve the program, move the needle, and what the next iteration is going to look like.