Adam Kipust & Erick Cheung, MD: Behavioral Emergency Response in LA County (11/8/24)

So welcome, everybody. Today we have two incredible speakers. Adam Quipust is from California, worked in ucla, and now he moved all the way to the east coast, and now he's a medical student and at my alma mater, University of Miami, he's an M.S.1. He's an M.D. and M.P.H student, and he's very involved in research. And you'll hear from about that today. And the lead author on this paper was Dr. Chung, who is the Chief Medical Officer at UCLA's Resnick Neuropsychiatric Hospital and the LA County EMS Commissioner. So, Adam and Eric, welcome. Take it away, gentlemen.

Awesome. Thank you so much. Good to see you, Dr. Chung. So I'm going to go ahead and get started here, and Dr. Chung is going to just kind of hop in as we go through this presentation. So today we're going to be talking about a program that LA County EMS Agency started back in 2016 to advance our capacity to respond to behavioral health emergencies.

And so as kind of a background, the EMS Commission, which is a regulatory body that oversees EMS within LA county, created an ad hoc work group with the objective to kind of improve how911 responds to behavioral health emergencies. And they noticed challenges in the system as it was. So there's high rates of mental health and substance use disorders within the population, and then there's rising demands for acute emergency mental health services. There was patient safety concerns in how EMS providers got in terms of care in the field, and then there's delays in care. I'm personally working in EMS of experience that waiting significant amounts of time, especially for behavioral health patients. And then there's the issue of stigma when law enforcement is involved.

In these patient encounters. And so kind of the fundamental question that this committee.

Aimed to answer is what happens when someone in la county calls 911 for a behavioral health emergency? Who's going to respond and who's making that decision? What sorts of evaluations will be performed on that patient, and where is that patient going to end up?

Initially, the committee first tried to evaluate what is the current state of EMS response to behavioral health emergencies. And then it transitioned into how do we improve what that current state was? And so to do that initial evaluation.

Guiding principles were kind of thought up of. So I think the number one guiding principle is that behavioral health emergencies are medical emergencies and should be treated as such. And I think that's really foundational to all of the work that was done. And then I think next is behavioral health emergencies are unique in their potential for agitation or violence, which requires appropriate response. Right so we want to make sure that our EMS providers are staying safe, that our patients are staying safe, and that the public is staying safe. And so these are unique patient situations that require unique responses. Next is that behavioral health emergencies are treated in facilities that are appropriately designed and resourced for behavioral health emergencies. I'm sure everyone in this meeting has experienced situations where either emergency departments didn't have the capacity or, or resources to potentially appropriately treat or even just the space to appropriately care for someone with a behavioral health emergency. So while some hospitals are really well equipped and have appropriate rooms and beds for patients with psychiatric emergencies, those beds are often limited in capacity and may not be staffed with appropriate staffing. 24, 7. And then I think our final guiding principle is that the pre hospital care system should be based on best practices, which I think everyone here can agree on that and is kind of a principle that that's taken across, you know, all areas of ems. So our commission was made up of a really diverse group of stakeholders, which I think made it effective. So we brought in groups from the county health agency. So Department of Mental Health Service, EMS agency was involved EMS providers. So we had the la, County Fire Chiefs Association, County Fire Department, variety of other EMS provider agencies. We had healthcare provider associations. And then law enforcement was also involved in this because both in what we'll talk about in a second in terms of dispatching, but also in terms of response. You know, law enforcement is often response or responding with us in these emergencies. Then we had public representatives and insurance providers all working together on this.

So in 2016, the Commission did a study and kind of analyzed how 911 calls were, you know, from the moment that someone calls 911, how is this behavioral health emergency being recognized and dispatched? So we did a survey of our PSAPs and we found that dispatch questions were not being standardized across the county. So depending on where you were calling from, you may be getting a standardized question to identify a behavioral health emergency, or you may not. And then it's often just a narrow question of is there injury, trauma or loss of consciousness that leads to an EMS response. But potentially, depending on who's working or where you're located, calling 911 might lead to a different response, just depending on who picks up the phone and how they interpret what you're saying. So there was a lack of standardization across the PSAPs. Next was law enforcement inadvertently criminalizes behavioral health emergencies. So, you know, kind of law enforcement, when they're responding, they need to make a decision, is there a crime or arrest or is this a medical mental health emergency? And then oftentimes, law enforcement, if they're responding to behavioral health emergencies independently, are put in a position where they're needing to conduct a clinical evaluation and call for ems, right? They need to decide, is this patient something that EMS are, you know, experiencing, something that EMS needs to respond to. And then when patients are being transported in law enforcement vehicles and handcuffs, that just increases stigmatization. You know, if that were your family member, I think, you know, or if it were my family member, I think it would be very difficult to see someone who's experiencing one of these, you know, behavioral health emergency being put into handcuffs and transported in a law enforcement vehicle. And next we looked at our own protocols. So, you know, as it stood, in 2016, the EMS agency really only had a protocol to identify agitated delirium and treat it with midazolam. Beyond that, there wasn't any sort of definitions or guidance on, you know, what are common mental health conditions and how to respond to those. And there was really no guidance or protocol on that on de escalation. And, you know, as I think everyone here is aware, there's pretty limited.

Education for EMS providers on behavioral health emergencies. And that's just, you know, kind of the nature. There's only so many hours that EMS classes have. So another big finding that we found was that destinations options really differed by whether EMS transported a patient or law enforcement transported a patient. So in 2016, the state law in California required EMS to transport patients exclusively to the emergency department, whereas law enforcement had other options to transport patients. So they could go to psychiatric emergency departments directly. They could go to psychiatric urgent cares, sobering centers, or even a freestanding psychiatric hospitals.

And then most DDs lack sufficient resources and expertise in optimally managing patients with behavioral health emergencies. And I think that's extremely true in rural areas or just smaller hospitals that lack the appropriate resources to treat these patients.

And then, you know, finally, substance use disorders, I think, lacked integration in the rest of our system. So there's limited available of sobering centers. And then even after patients were, you know, seen in the emergency department, I think emergency department clinicians often had trouble placing patients into dehox and rehab from the ed.

So we went ahead and we looked at how can we redesign this system.

And so we wanted to see if 911 can. Right. The goal of the PSAC should really be to identify dangerous behaviors and then go ahead and dispatch appropriate, you know, law enforcement if needed, for dangerous behaviors and EMS for non. For nonviolent behavioral health emergencies. And then we wanted to make sure that we had law enforcement co responding for any actual or potential violent threats to patient safety or. Or to provider safety or to community safety. Right. Law enforcement is essential for that. But we also wanted to make sure that EMS had the enhanced knowledge and training for behavioral health emergencies and have EMS as the preferred patient transport. Again, like we spoke about before, having law enforcement transporting can further stigmatize people who are experiencing these emergencies. Next, we worked on broadening destination options for EMS transports and integration of alternative behavioral health responders.

So in.

2018, we started taking action on these policies or on these. On this kind of work. And so one of the first things which Dr. Chung was really instrumental in implementing was initially a pilot program that would allow transferring of calls from LAPD to the suicide lifeline. And so suicide lifeline is similar to kind of how 911 is made up of a lot of different PSAPs. 988 is made up of a lot of different local nonprofits that answer calls. And so there was a partnership between a local nonprofit that's part of the 988 system and that allowed LAPD to transport or transfer phone calls directly to the suicide lifeline. And that started as a pilot, which showed a really small percentage of these calls requiring later response by either EMS or law enforcement. And so now that's a fully operational program.

Next was an overhaul and augmentation of EMS treatment protocols for behavioral health emergencies. And we'll talk a little bit more about those protocols on our next slide here. And then we offered alternative transport destinations for EMs. And in 2021, I think it was AB 1544 allowed for this to kind of be a permanent policy change. Initially, it started out as just kind of small pilot programs, but it allows for EMS providers to transport patients to psychiatric urgent cares or sobering centers, directly circumventing the emergency department.

And then, you know, we did some work supporting law enforcement and EMS in leave behind naloxone and having law enforcement care in naloxone with them. And then as part of our annual EMS update, the EMS agency worked to include education on these new protocols. And so the county had over 4,000 paramedics get education on this.

And so these are our new and updated EMS policies. So this QR code here will actually, if you scan it, there'll be a link to the LA County EMS agency website, and you can click and read through any of these policies that you'd like.

But we introduced new policies, so care of the patient with Agitation. And we included explicit instructions on verbal de escalation as well as common etiologies of agitation and when intervention is appropriate in these patients. So for example, someone who's having agitation as a result of a medical complaint, we want to treat that medical complaint.

Then we introduced a new pharmacologic agent. So olanzapine atypical antipsychotic was introduced as an orally dissolving tablet as an option for paramedics to give for patients. Like we talked about before, patient destination. So initially this started as a pilot and went into full implementation. And so it created medical clearance criteria for psychiatric urgent care transports as well as sobering centers. And then we had specific policy on EMS and law enforcement.

There's current work going through to introduce suicide risk screening as a protocol, so allowing paramedics to complete a formalized using the Columbia Suicide Severity Risk Scale to.

Screen patients for suicidality and determine whether they potentially need to be transported to the emergency department. And just kind of give a common language to paramedics and hospital providers. And then we went through and updated some old.

Policies. So behavioral health, psychiatric crisis, application of patient restraints and the agitated delirium protocol was retired and kind of integrated with the care of patient with agitation.

So that is all that I had. Dr. Chung, do you want to hop in? Add anything?

Great presentation, Adam. I don't have much to add except to point out in the chat it was posted with the link, really practically speaking, for the EMS system, the most sizable change is what you can do to improve or what we did to improve our own policies. And the build out of the care of the patient with agitation was a very significant exercise, quite detailed, very informative, and is now the basis for training of EMS in our county. And there were additional resources. It's actually a four part policy with different resources and flowcharts and approach to scene safety. So if the group desires, we can get into that a little bit more detail. This is a high level presentation of all the different areas of work that were done. But from my perspective, really scrutinizing the deficiencies in our policies and building them out was, was probably the most notable thing that happened over the past several years.

Yeah, and I would just jump off of that to kind of say that, you know, you know, the work that we did was obviously specific to LA county. And it may not be that these policies are what work within, you know, your specific agency, but I think it's important to take the time to, to go through and see and do an evaluation of what would potentially Work in your county? What does your county or your EMS agency's current response look like and how can that potentially be improved?

I'll say one more thing, you know, if you went ahead to take a look at some of the policies, basic stuff like providing definitions about what the different types of mental illnesses that are commonly encountered in that field, we, we felt was actually quite helpful because there's a lot of misunderstanding, basic misunderstanding among providers in between providers and hospitals and patients around what's the condition I'm dealing with. When somebody says my son has autism, that doesn't mean the same thing to everybody. So being able to describe and have basic understanding of what's autism, what's psychosis, what's dementia, what can you expect when dealing with these? And what can you expect with regards to specifically the potential for verbal de escalation, which was really the emphasis of the care of the patient with agitation to put something on the books that describes how to do verbal de escalation when it would be most appropriate and what you could expect with the different conditions. And that was, you know, a large part of this.

Excellent. This is a very important topic. I really appreciate what you guys have done and I want to bring some people in here. My first just kind of overall comment is that I really like what you all did, which was standardizing dispatch, looking at your protocols and modifying your protocols, allowing the alternative transport destinations. It's kind of like a nice three pronged approach. The question I have for you is what can you help us learn with respect to dealing with your law enforcement partners here? It would seem to me that, you know, people are just accustomed to doing things a certain way, whether it be from the dispatch on down to how EMS interacts with law enforcement. Can you give us some lessons learned, if you have any, with respect to the law enforcement modification with this new protocol?

I'll say a few words about that. That is just so critical. And it's one of the unique aspects, I think, of the psychiatric emergency that's rather unfortunate, I'm sure. I'm guessing in Florida, much like California, the default mode here is that law enforcement has hold placing authority. They're involved in all the involuntary situations. And I think, you know, speaking bluntly here, EMS providers, much like the rest of the healthcare system would, would in many ways rather not deal with the behavioral health emergency or the psychiatric emergency and actually leave that to law enforcement. One of the things that these policies did and that that first principle that was read off by Adam did is say that behavioral health emergencies are part of the human body just like anything else. And our medical emergencies. Therefore we are the best first responder unless we need law enforcement. So actually one of the big first steps was to convince and compel EMS to take this on as part of the job. And I'm not saying they didn't know that, but there's a stigma that underlies this. So that actually was a pretty big culture shift for us that we're still going through. Law enforcement is a great partner in LA County. I'm actually pretty impressed with that. Has a very tight connection with the EMS agency. They sit in our commission meetings. We involve them in virtually everything we do and they appreciated that we wish to take on the non agitated situations and the nonviolent situations so that they could get involved in where they are really most needed, in the situations where public safety or provider patient safety are most at risk. And it spares them a little bit of having to respond to the lower level issues, ones where we can talk it out. In essence, they don't need to go to those ones. We can handle that. That's what we should be doing as ems. But when you've got somebody with a weapon or has otherwise threats to public safety, let's have law enforcement there for a co response. We're still handle the medical situation, they handle the safety situation. And we'll do that dance and interact as much as we need to. We have an ongoing EMS law enforcement co response committee that grew out of this effort. The value of having partnership around creation of our policies and CO education is really important. We've had several agencies go on to develop.

Co response training within their different jurisdictions, which is very helpful. Hard to make that universal. But some places are striking out and being very innovative on their own and they're using the basis of these policies as the backbone for education on both sides. Peter, one thing that is hanging out there that I want to mention that we are working on today, actively this year is the response for suicide and suicidal patients. You'll notice that I guess we didn't read off the it was fast. But you saw the list of all of the different policies. That was a huge one. It's a third or even 40% of the responses of EMS or law enforcement in the field and is one that we felt we couldn't tackle given the big amount of changes we made and that that was going to be a sizable lift. So we're working on that now and are deep into it and it's proving to be difficult, challenging. I'll be honest with you to get EMS providers on board with doing something more standardized around evaluation of patients at risk for suicide. This is one of probably the most unfortunate things, is that patients who are not violent are having suicidal crises, are having law enforcement show up, and it's probably just, it's just not the best response. They don't have, they don't have the medical background and the training to be able to do good risk evaluation in the field and to communicate with the hospitals about what's needed next for the patient.

There's so much to unpack there, and I wish we had more time. And so I think maybe we should have you guys back because just that last piece that you just talked about with respect to the, the different meetings and educations that you're having and the suicide issue, I think we should explore that further in the future. So. But I'm going to bring in my co host, Tanner Smita. So, Tanner, any comments from you?

Yeah, first of all, thank you both for coming. Adam, you know, as somebody who is a former EMS provider going on to medical school, being in a dual degree program, focusing on research might be a little biased here, but I think you're going to do great things.

But so in terms of, in terms of the actual topic, you know, I think that this is really important just first of all, because, you know, so much EMS research focuses on, you know, trauma and cardiac arrest. But, you know, psychiatric emergencies is something that we encounter, you know, every shift, you know, especially if you work in a metropolitan area. And there's not a lot of research out there on, on how to best deal with these, this population of patients. So, so, you know, kind of the first series of comment and questions I had for you is about kind of the epidemiology of the patients we see in the field. So, so the way, the way I see it is there's kind of a, or at least my impression so far, working as an EMS provider is that there's a, there's a very small proportion of patients who require true intervention by ems. Right. The patients who are a danger to themselves or others and are agitated, require medication with pharmacology or restraint. And then you have patients who, another population of patients who the encounters are related to substance use, you know, whether that's, that's alcohol or opioid use, as you mentioned. And then finally, and I think this might be, at least in my practice, the biggest population of patients that we encounter are patients who have kind of refractory, either suicidal ideation or they have chronic psychosis. And so they're encountered repeatedly by EMS providers, often involuntarily committed to the hospital.

And something that I hear from colleagues in psychiatry and elsewhere is that repeated hospitalization is really not the solution for these patients. And the hospital systems really don't have solutions for that group of people. So I guess my first question is, is that kind of epidemiologic characterization correct? And then second of all, you know, you talk about alternative destination. So instead of going to hospitals, going to psychiatric urgent cares. I've never heard of psychiatric urgent cares. We don't have those in West Virginia, as far as I'm aware. So I'm just curious in terms of the care that these alternate destinations are able to provide relative to hospital care, you know, what are they doing? Are they starting new medications? Are they optimizing existing medication regimens? Are they looking at kind of therapeutic plasma levels of medications, you know, what care is being provided for kind of.

That, that population of patients go in reverse order. The psychiatric urgent care centers are a developing cohort of alternate destinations. There's at this point in time probably about a dozen in addition to the three dedicated psychiatric emergency departments and maybe 12 to 14 in a very large metropolitan area. As you know, LA is and 10 million people here. So it's a very small number comparatively. But they're beginning to serve a critical purpose. Because of the protocols that we built out. When the provider agency and the urgent care center have completed their requirements to be able to qualify for alternate destination allows them to transport their instead of to the nearest ed, the psychiatric urgent care is staffed with mental health clinicians, number one. Right. So when you go there, it's not like you have to do all the other stuff. Yes, you're getting a medical screening exam and you're medically cleared. And a very small percentage, a couple percentage, any given year may have to go over to an ed, but you're getting to the right place with the right provider quicker. And it's in an environment that is more appropriate for mental health emergencies, doesn't have all the busyness of the ED that we all know. So with mental health providers with an environmental build out that is more appropriate and with people who have the expertise to be able to treat and prescribe and begin treatment virtually immediately for whatever the condition is, whether it's chronic, as you're pointing out, very common, or acute on chronic, they can get that going and it's a 24 hour maximum stay. They have to figure out disposition by that point in time, or so the law says. Nothing happens if they can't do it by then and the patient is still there. And from the psychiatric urgent care standpoint, a smaller percentage of those patients go on to need inpatient psychiatric hospitalization compared to the population who go through eds. And that's probably because of the ability to have more careful decision making on the one hand, and really determine is inpatient needed and the case management and social work resources that go in on the back end so that it's not just a discharge back to where they were, a discharge back to the streets. They're making active attempts to link to care, to outpatient care, to the next appointment. So that's kind of the model of the psychiatric urgent care, just in case you're interested in exploring this. Psychiatric urgent cares go by many different names. That's just kind of the, the terminology here. Crisis stabilization unit is another term for that. And then there's another kind of model called an empath unit, which is the transfer out of ED as quickly as you can once the MSC has been done, so that you don't have to do the rest of the evaluation and boarding in the ed, but you do a medical screening exam and then go to an empath unit. There's just a couple of different ways you can do this. And both have shown to be successful.

And then so. And actually I want to just jump in and add one more person here who's been a very tremendous figure in state of Florida with this type of model. So, Dr. Ken Chepke, Deputy Secretary of Health for the State of Florida, what do you think of the presentation and any comments with respect to the Florida aspect of what we can do here, what you're already doing here with respect to this.

Yeah, fantastic presentation. Thanks very much. And certainly an area where we need to change the current model. We all know that the emergency department is not the correct destination for a whole slew of patients with behavioral health emergencies certainly being one of them. I have a quick question for you though. With the alternate care destinations.

Financially, how are you doing that here? Our EMS gets paid if they go to the emergency department. If you go to an alternate care destination, there's no reimbursement. Now, I believe that that would probably save the healthcare system money if you go to the appropriate destination initially. Do you have any information on the financial impact of this course that you're doing?

So that's a critical question. We began to touch that for some time. The short answer is I'm being a psychiatrist and a doctor who works not actually in the EMS system But in the eds, I don't have to worry about that. Right. So I don't have an answer, but for you immediately on it. But let's connect you with the EMS agency on that. It was a topic that we were discussing importantly at the beginning. I believe with the regulatory changes that occurred. It allowed at least for the potential for ability to bill in that direction or receive reimbursement. It was a regulatory change that was critical to begin with because if all the regulations say transport to the mar, to the nearest edge, no insurer, no.

Funder is going to pay for something that's regulatorily not allowable. So we made that change in collaboration with other EMS agencies across California. And what I don't know is whether we have actually been able to see providers be appropriately reimbursed for that alternate transport. So we'll connect you with the right people on that.

And I.

Know that the legislation did include some verbiage that at least recommends or encourages reimbursement for it, but I don't know if that's, that's, there's actually been implementation of it.

So. Ken, Ken, let me just double click on that. You're saying that if we go to an urgent care standard, urgent care, not psyched urgent care, because we're actually moving in this direction in Brevard county, that's not going to be reimbursed because currently Florida statute doesn't allow that.

I'm not sure that's a statute thing. That may be a third party payer thing. I don't really know exactly, but I'm trying to dive into that. What I'm hearing from EMS agencies is they collect only when they go to the emergency department, if they go to an alternate destination, whatever that happens to be. And that's where that ET3 model that Medicare set up was attractive because actually reimbursed you, at least from a Medicare standpoint, for taking patients to alternate care destinations such as behavioral health places. So it's one of the things that we are exploring here that I've been personally exploring because I think models like this make the healthcare system far more efficient. But the current payer system is a barrier to implementation of this because right now, if you're only paid to go to the emergency department, you are disincentivized financially to take the patient to a more appropriate location, like a behavioral health emergency, because your agency, frankly may not be able to afford to lose that revenue stream. So that's why I'm interested in models like this. I think there's A lot of different models that do, whether it's behavioral health or other different things. And there's another a number of pilots, and the pilots all work on grants. But I think what we really need is a sustainable source of funding that allows for these alternate care destinations, taking the patients to the appropriate for whatever their underlying issue may be. And maybe it's urgent care, because it's a minor case, which would be far less expensive for that emergency department. Maybe it's behavioral health and so forth, or maybe even treat and release at home for which there's no reimbursement. So those are all things where I think.

There'S building evidence that's more efficient, it's better for the patients, better for the system, because it frees up resources for those true seconds to minutes emergencies that are in your jurisdiction. But the financial piece, I think, has not been solved yet. So that's, I'm interested if there's any information on that.

Yeah, that's a great comment. And I think that we have so much work to do on this. But when you look at what these guys presented today and what's been done in California, I mean, it's all kind of blatantly obvious that this was the right thing to do. But what I was struck by was the timeline. I noticed, Adam and Eric, that you guys started this in 2016 and here we are in 2024. Paper just comes out meaning that now it's kind of like more mature and it's happening. And that's because I presume it took you all that time to change hearts and mind, change the law, education, transforming the thought process, getting these structures up and running policies, et cetera, funding. Do you, do you think that what you've done, what you have done is an insurmountable challenge for others given the fact that California is so well organized, you know, lemsas, et cetera, versus other places around the country. Or do you think that your model is, quote, unquote, kind of copyable in other. In other places?

Adam, do you want to make a comment on it or.

Sure. I mean, I think to start with, you know, it, you know, I only got involved in maybe 2020, 2021, but I think, you know, just having a regulatory agency really leads to a lot of oversight and there's a lot of different players that need to be involved in order to make decisions. And I think, you know, states like Florida, where medical directors maybe have more jurisdiction directly over their agencies, there might be more flexibility to try and implement or pilot some of this stuff. More rapidly. But I think yeah, it took a long, long time to pilot to get buy in the suicide screening tool in 21. I went out and did some ride alongs with a crisis unit that was trialing this program and I think it took a long, long time to get buy in from the clinicians, the EMS clinicians in. It takes time. It takes, you know, them seeing this in action and really thinking through it to make a change.

I'll make a comment. I'd like to think that we, we hopefully have, have made it easier for anybody who wants to, to do something like this. We, you know, there wasn't, as you're pointing out, there was not like there was a model we could follow. There were policies that are already out there that we could just look at. Adapt Copy. We were doing a lot of research from the, from the ground up to figure out who's doing what. Is there anything in this space? Writing a protocol on de escalation and management of agitation took quite some time. But now that this is out there, you know, you're, it's publicly available, you're welcome to take it, you're welcome to tear it down, use it as a basis for your work. I think that if any agency or any, any providers wanted to do something similar, you're probably in, in roughly a one to two year cycle to just build out the policy and then do. That's really what it took at the end of the day. We wrote our policies within a year, had a committee work on this and then we educated over a year with the resources within the agency and two, two and a half years later, everyone's educated and at least now knows the basis of what's expected when they respond in the field and have some tools, have some information about what to do with the agitated patient and how to approach the psychiatric condition in general. We are not yet there on suicide risk evaluation. I hope we get there. As I said there's, there's actually a lot of resistance to this one which is interesting to me. But I don't think, you know, education is going to be a low hanging fruit. We spun our wheels in the first couple of years, you know, beating our heads against the wall around regulatory and we were, you know, going up to Sacramento related to the alternate destination. So I think we may not have started in the best natural spot which is just deal with the things you have direct control over like your policies. That came later, that came more towards 2020.

Right.

You know, kind of as the pandemic gave us a little breathing room in 21 or 2. We could start to work on that.

One last question real quick, Peter. I know we're probably over. I know Dr. Eckstein mentioned the sobering centers at Eagles years and years ago. And so my question is, rather than just harm reduction and letting those folks do that, are those centers also placing your opioid use disorder patients on Suboxone? Placing your alcohol abuse patients on a camper, say these medications we know work very well in these patients, but seem to be grossly underprescribed. Are you doing that?

Yeah, I think they're doing that to some extent, especially on the opiate side. One of the biggest challenges, I'm sure you're recognizing this too, is starting it, but then continuing it. So making sure that when you start something, it's not just you do it for a day or you do it for six hours, that, that, that next continuity of care, that next step is so critical. That's been always the big barrier is we can start it, can we continue it? And. And so I think they're still. They're doing some of it, but still struggling to really make that connection.

Thanks.

The great part about the cross pollination. Let me go quickly to Lou, and then we're going to finish with Tanner and make a final comment. Go ahead, Lou.

So I just wanted to emphasize the pre planning and the pre training with law enforcement. It's incredibly important because sometimes, as we've seen, law enforcement escalates the situation. When does the handoff occur and how do we de. Escalate it? And number two, keep in mind that behavioral emergency might be hypoglycemia, might be hypoxia, that we have to be involved to recognize that, hey, this is really a medical emergency, not a psych problem.

Very well. That's a great, great comment. Awesome. Thanks, Lou. All right, Tanner, take us away, make any final comments, and then we'll hop over to Dr. Pepe's webinar.

Sounds good. Yeah. Again, thank you both for coming. I think for all of the rest of us, I think that work like this should be a call to action, not only to look at the care of this vulnerable patient population on a nationwide scale, but also in all of our own systems, look at our own data, see how we can approve kind of our. Our systems of care for psychiatric emergencies, to. To make our systems as good as they can be, both for. For patients, both for the. The financial health of our systems, et cetera. So again, thank you very much. Appreciate it.

Thank you guys very much. Eric, Adam, thank you guys. And this is good for cross pollination. You mean now we know who the players are and we'll be sure to keep in touch. If we have any questions, we'll reach out. Thank you so much.

Yeah, thanks for this. And be sure to check the policies. If you have any questions, let us know and we'll get a link to Ken on the payer situation.

Yeah, I think Ken with his position he can make massive improvements here at the state. So I think hearing him being here and hearing your presentation was just very, very critical. So thank you guys very much.

All right, good luck.

All right everyone feel free to click on the link on the right hand side. You're going to get right over to Dr. Pepe's webinar and we'll see you guys on the other side. Make sure you fill out your CME 19445 for our session 1-9444. So if you go to both, you'll get two CMEs for today and then use Cloud CME. If you you do not know how to do that, just let me know and I'll get you hooked in. And make sure you join our Florida dinner in San Diego on January 10th if you're going to be at the NMSB. With that said, see you next week everyone take care of.