Clinical Scorecard: Reevaluating Post-Emergency Department Care for Behavioral Health: Transitioning from Crisis Management to Ongoing Support
At a Glance
Category
Detail
Condition
Behavioral health conditions presenting to emergency departments
Key Mechanisms
Acute stabilization in ED followed by transition to outpatient or community-based care; challenges in care continuity and integration
Target Population
Medicaid beneficiaries with behavioral health–related ED visits
Care Setting
Emergency department, primary care, specialty behavioral health, community-based services
Key Highlights
Only 11% to 14% of behavioral health–related ED visits among Medicaid patients are followed by condition-concordant primary care within 30 days.
Low primary care follow-up rates reflect fragmented care pathways and limited primary care capacity rather than absence of care.
Disparities exist with lower follow-up among non-Hispanic Black beneficiaries and individuals experiencing homelessness, highlighting structural barriers.
Guideline-Based Recommendations
Diagnosis
Recognize behavioral health ED visits as entry points for acute stabilization and risk assessment.
Management
Prioritize primary care and transitional care resources for patients at highest risk of clinical deterioration (e.g., multiple chronic conditions, frequent ED use, unstable housing, co-occurring disorders).
Implement ED-led transitional care models to coordinate follow-up and ensure sustained connections to longitudinal services.
Monitoring & Follow-up
Monitor follow-up care not only by occurrence but by patient risk profiles, timing, care setting, and provider type.
Address disparities by tracking access and outcomes among marginalized populations.
Risks
Risk of fragmented care and unclear accountability post-ED discharge.
Potential exacerbation of disparities if follow-up efforts are not equity-focused.
Overburdened primary care capacity limiting timely outpatient access.
Patient & Prescribing Data
Medicaid beneficiaries with behavioral health–related ED visits
Established primary care relationships facilitate follow-up; lack of such relationships increases barriers. Fragmented systems and limited interoperability hinder timely outreach.
Clinical Best Practices
Design post-ED follow-up strategies with equity to mitigate structural barriers affecting marginalized groups.
Strengthen Medicaid primary care capacity through adequate reimbursement, clinician networks, and health information exchange.
Assign accountability for post-ED care transitions to the ED to reduce fragmentation and improve coordination.
Optimize resource allocation by targeting intensive follow-up to high-risk patients while managing others with brief interventions or routine referrals.
Invest in community-based behavioral health services to support sustainable recovery beyond the ED.
