Designing for Mental and Behavioral Health Needs — Crisis Care Spaces within Emergency Departments

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Why Is This Important?

It is estimated that in the United States 1 in 8 visits to the emergency department are for a mental health or substance abuse issue. The emergency department can act as the front door for many experiencing a mental or behavioral health (MBH) crisis. This initial visit has the potential to impact how that individual feels about the health care system and their own ability to get better. For this reason, it is a vital step in our nation’s mental and behavioral health treatment plan to provide adequate and human-centered care for MBH patients presenting to the emergency department in crisis.

ORIGINAL GRAPHIC. CONTENT DERIVED FROM: Substance Abuse and Mental Health Services Administration. (2018). Key Substance Use and Mental Health Indicators in the United States: Results from the 2017 National Survey on Drug Use and Health.

This study examines psychiatric crisis care spaces (e.g., crisis stabilization units, holding units) and their role in impacting the health and well-being of individuals presenting in a MBH crisis. Insights into the multitude of factors influencing the need for psychiatric crisis services and opportunities for how design can respond and support human-centered care were also explored. By delving into the field of MBH in crisis care environments, we can provide insight into how we as designers can challenge our own understanding on designing the environment for someone in crisis.

What We Did

This study utilizes a review of the literature, industry expert interviews, a think tank, and analysis of case studies to examine the role of design in psychiatric crisis care spaces on facilitating patient health.

A literature review was conducted to understand the systematic problems facing mental and behavioral health care. Twelve industry experts in the design, research and planning field of health care facilities gathered to discuss trends in emergency department planning and behavioral crisis care. For insight on the current state of crisis care environments, semi-structured interviews were conducted with experts in the fields of architectural planning and design of emergency departments and MBH facilities along with care providers of psychiatric and emergency medicine. Five case studies were selected based on their demographic location, potential patient population, and facility age. These were analyzed demonstrating the variety of design options based on patient population and operational strategies.

What We Found

Review of the literature: Many design responses for crisis care environments have not gone farther than provisions for physical safety with limited guidelines or tools that support human-centered design.

Interviews with industry experts: The operational and physical environment of emergency departments can clash with psychiatric care processes.

Think Tank: Understanding the patient population is vital to designing crisis care environments and the impact on ED planning.

Case study analysis: Design responses across the case studies show a vast difference in how environments can be designed for MBH patients.

Access measures include access to insurance, treatment, special education, quality and cost of insurance, and workforce availability. Higher access ranking indicates that a state provides relatively more access to insurance and mental health treatment. GRAPHIC ADAPTED FROM: Hellebuyck, M., Halpern, M., Nguyen, T., Fritze, D. (2018). The State of Mental Health in America 2019. Alexandria, VA. Mental Health America.

Four factors were identified as influences in MBH crisis care:

Social Factors
Socioeconomic factors influenced by federal and state lawmakers disproportionately impact Americans. This has been shown through census data on emergency department visits and access to care. Social stigmas have a substantial impact on public health and may negatively impact opportunities for good jobs, housing, and health care.

Operational Factors
The variations in appropriate staff training for psychiatric care within emergency departments is a prevalent issue. Literature pointed to more emergency medicine staff being cross trained to care for those presenting with a MBH condition. Security protocols for MBH patients in the ED was found to often dictate the clinical protocols for this patient population.

Built Environment Factors
Literature reviewing patient experiences within emergency departments stressed the trauma reported from the ‘cold’ & ‘clinical’ environments when visiting the ED in emotional distress.

Built Environment Factors
Individual factors such as self-stigma’s and specific MBH conditions were reviewed to better understand the range of care needs. Patients with severe mental illness were found to have an increased risk for poor clinical outcomes despite the increased resources utilized or their length of stay. A substantial portion of the literature reviewed demographics of ED visits with many MBH patients presenting with physical ailments as their chief complaint, supporting the knowledge that co-morbidities are prevalent in this patient population

Findings and insights from the literature review, interviews, think tank, and case study analysis led to the development of key considerations, design goals, and a design considerations checklist for crisis care environments, which are compiled into a comprehensive report of the study.

What the Findings Mean

For many, the emergency department may serve as one of the only choices to receive care. What we have learned from psychiatric care, is that MBH patients have specific needs that may conflict with the typical operations of emergency departments. This environment is challenged to function for both while supporting patient-centered care. By having a clear understanding of who is expected to be served, designers can better plan and design environments to support this patient population.

As the rise in mental health service needs increases, so should our efforts in designing environments that support both MBH patients and care providers. This is our call as designers to respond with knowledge through design and strategies that maintain human-centered MBH care for all.