A Qualitative Study of Barriers and Facilitators to Transitions From the Emergency Department to Outpatient Mental Health Care

People with psychiatric disorders are among the highest users of emergency department (ED) services (1, 2). Moreover, ED admission rates due to mental and substance use disorders have increased significantly over the past 10–15 years (1, 3, 4). In 2014, almost 3.5 million ED visits were due to a psychiatric disorder or suicidal ideation (4). Compared with individuals without a psychiatric diagnosis, people with a psychiatric disorder are more likely to report frequent ED visits (5, 6) and longer lengths of stay (7).

Successful transition to community-based outpatient care may be important for ensuring continuity of care and improving patient outcomes. However, patients have reported significant gaps in discharge planning and transitions (8). After discharge from the ED, only about half of patients with a psychiatric disorder attend an outpatient visit (9–11).

People with psychiatric disorders face various barriers to accessing outpatient mental health services, including being unable to afford treatment, not knowing where to go, not having enough time to attend appointments, believing that they can handle the problem on their own, and perceiving that treatment will not help (12–14). Additionally, people with more severe psychiatric symptoms may also be less likely to attend appointments (15). Although many of these barriers likely apply to individuals with psychiatric disorders who are referred to outpatient care after ED discharge, some barriers and facilitators may be particularly salient for this population. A 2017 systematic review found only three studies examining mental health service users’ experiences in EDs in the United States, with none examining how these experiences were related to subsequent engagement with outpatient mental health care (16).

In this qualitative study, we examined the following question: What barriers and facilitators do patients face in transitioning to and engaging in outpatient care after ED discharge? We explored the perspectives of patients and providers on these factors at the patient, provider, and health care system levels.

Methods

Study Design

The qualitative data used for this analysis were collected as part of a larger study assessing transitions of care from EDs to community mental health centers (CMHCs) for people with psychiatric disorders receiving care management services. Study locations included three urban, two suburban, and three rural ED and CMHC pairs. The CMHCs are funded and run by the South Carolina Department of Mental Health and provide an array of adult mental health services. The research team that collected and analyzed the qualitative data was not involved with training for or delivery of the care management program. The team was led by two faculty members in public health (one psychiatrist and one qualitative researcher) and included two students pursuing a master of public health degree and a staff member with previous qualitative experience.

We conducted 45 in-depth, semistructured interviews with patients (N=30) and providers (N=15 interviews with 13 providers). All study procedures were approved by the institutional review boards of Emory University, University of South Carolina, and the South Carolina Department of Mental Health. Data collection occurred through two rounds: the first in February–August 2018 and the second in January–May 2019.

Sample

For the parent study, patients were eligible to participate if they were admitted to one of nine EDs with a primary psychiatric diagnosis (ICD-10 codes F20–F48), were age 18 or older, had a discharge plan to one of eight participating CMHCs, and lived within the CMHC catchment area. Individuals were ineligible if they displayed cognitive impairment (17), did not speak English, or were admitted to the hospital from the ED.

At 6- or 12-month follow-up, participants were invited to participate in a qualitative interview. Interested individuals were contacted by phone to review the interview consent form, answer any questions, and schedule the interview. Patients provided informed consent either verbally after the researcher read the consent form or by signing and returning a consent form by mail. During the 2018 data collection, 39 patients were reached for follow-up, 31 (79%) indicated interest in a qualitative interview, and we completed 15 interviews (48% of interested individuals). During the 2019 data collection, 66 patients were reached for follow-up, 53 (80%) indicated interest in an interview, and 15 interviews were completed (28% of interested individuals).

Outpatient mental health providers who provided care management as a part of the parent study were eligible and invited by e-mail to participate in an interview. The providers included certified peer specialists who offered individual or group peer services and licensed clinical professionals (e.g., therapists, counselors, and social workers) who provided therapy and counseling services. As part of the care management program, the providers aimed to complete a warm handoff call while the patient was in the ED or soon after and six monthly visits at the CMHC. Care managers delivered care directly to patients and, as appropriate, linked patients to other providers in the CMHC. Providers who agreed to participate were e-mailed a consent form, which they signed and returned through secure e-mail or fax. We completed 15 interviews with seven of 14 eligible providers (50%) in 2018 and eight of 21 eligible providers (38%) in 2019. Providers could participate during both waves of data collection, resulting in two providers who completed two interviews. All participants received a $50 money order as compensation for their time.

Data Collection

The research team developed two semistructured interview guides informed by qualitative data collected in the formative phase of the study (18). Following multilevel theoretical models of access and engagement with health care (19), interviews were structured to examine the patient-, provider-, and system-level factors to accessing care that precipitated the ED visit and facilitated or hindered outpatient follow-up after discharge. We also focused on two categories that have been found in surveys to affect engagement with care: attitudinal barriers, such as belief that a problem does not require care or that treatment is not effective, and logistical barriers, which include factors such as lack of transportation or inability to pay for services (12). The patient interview guide covered the following domains: use of the ED, transition to the CMHC after discharge, barriers and facilitators to attending appointments, and interactions with mental health providers. The provider interview guide covered the following domains: provider assessment of patient barriers and facilitators to engagement in care, challenges and facilitators for transitions from the ED to the CMHC, and interactions with patients. The interview guides elicited responses about overall engagement to care, conceptualized as attending any appointments at the CMHC, and were not focused on engagement in the care management program.

Interviews occurred over the phone and lasted between 15 and 60 minutes, with an average interview length of 30 minutes for patients and 45 minutes for providers. All interviews were digitally recorded, transcribed verbatim by a professional transcriptionist, deidentified, and reviewed for accuracy. Transcripts were uploaded into the qualitative software package MAXQDA, version 18, for data management and analysis.

Qualitative Analysis

Thematic analysis, a flexible method of identifying main patterns in the data, was used for analysis (20). An initial codebook was developed deductively on the basis of questions from the interview guides and predefined categories of barriers to treatment (12). Additional inductive codes (e.g., comfort with provider, readiness to engage in treatment) were added after we reviewed notes and transcripts. For each round of data, the study team coded four transcripts together by hand to discuss and align coding. Transcripts were then separately coded in MAXQDA by two team members (E.R.W. and either J.F., M.M., or J.N.). The first author (E.R.W.) reviewed all coding to ensure reliability and updated the coding when necessary. The team wrote memos summarizing codes and relationships between codes and compiled matrices, stratified by patient and provider groups, to summarize and compare coded segments at the patient, provider, and health care system levels. Themes on the barriers and facilitators to care were identified at each level and compared across patient and provider groups to determine the degree of convergence.

Results

Our sample included 45 patients and 13 mental health providers (Table 1). The average age of patients was 37 (range 20–63). A majority of patients (60%) identified as male. Most patients self-identified as Black (47%) or White (43%), with two patients (7%) identifying as Hispanic or Latino. Patient diagnoses in the ED included depression (47%), bipolar disorder (23%), and psychosis (13%); 27% of patients had comorbid psychiatric diagnoses, and 10% also had a substance use disorder. A majority of participants (63%) attended at least one visit at the CMHC within 30 days after ED discharge, which was higher than for the full sample in the parent study (49%, N=155). Of the 19 patients who attended an appointment after ED discharge, only five had a visit to the CMHC in the 6 months before enrolling in this study. This finding indicates that 74% of patients who engaged with the CMHC after ED discharge did not have recent prior engagement.

Almost all of the mental health providers identified as female (92%). The provider sample consisted of 46% certified peer specialists and 54% mental health professionals. Peers and professionals described similar barriers and facilitators to engagement in care, except where noted below.

Patients and providers described factors that hindered or supported patients in attending appointments at the CMHC after discharge from the ED. Overall, patients experienced multiple, often longstanding, barriers to engaging in care. Patients who were and were not engaged at the CMHC after ED discharge experienced similar barriers. These barriers and facilitators are described next and summarized in Table 2.

Patient-Level Barriers and Facilitators

Patient-level barriers and facilitators to transitions and engagement with care were clustered into two themes: openness to treatment and logistical factors, which included transportation, financial insecurity, and competing priorities.

Openness to treatment.

Patients and providers described attitudinal barriers and facilitators to seeking treatment. Patients described hesitations and benefits to attending outpatient appointments, whereas providers’ descriptions focused on patients’ readiness to engage.

The ED was an entry into the mental health care system for several patients who had not previously received a diagnosis. After they had received the diagnosis, some patients realized that they had been dealing with symptoms for a long time and could benefit from treatment. Other patients avoided engaging in treatment before their ED visit because they had difficulty reaching out for help or felt they could handle the symptoms. One patient stated, “I think I just kind of delayed it because . . . I thought I was at a point that I could handle things on my own, but around that time it was a lot stressful.” Patients mentioned being hesitant to attend appointments because they were afraid of judgment from family or health care professionals or felt “embarrassed.” Some patients discussed being open to treatment and the benefit of attending appointments. One patient stated, “Sometimes I will get stubborn and not tell anybody that I need help, but usually like a day or so after I end up in the hospital. I try to be open with my therapist and tell her that I need help.”

When discussing engagement, providers commented on the patients’ readiness to receive care, such as the need for patients “to make the choice” to engage in their care and be committed to their treatment. One therapist noted, “The biggest barrier is they’re just not ready, you know? They’re not always willing to own that, but you as a counselor, you just kind of feel it, you know? They’re just not ready to make that drastic lifestyle change, or stigma I think is still a big part of it.” From the providers’ perspective, it can take a while for patients to be ready to engage in mental health care.

Logistical barriers: “I can’t get there that much.”

Living close to the CMHC and having a reliable car were common facilitators to attending appointments. Lack of reliable transportation was the most frequently mentioned barrier by patients and providers. Some patients relied on family members for rides, although people providing rides were sometimes unreliable or unavailable when needed. Transportation was particularly difficult for patients who lived in rural areas with limited public transportation. Patients with Medicaid could use a Medicaid van to bring them to the CMHC, although the number of rides was capped. Issues with transportation intersected with financial difficulties when patients had difficulty affording gas or fares for bus or cab rides.

Other elements of financial insecurity included unemployment, not having insurance, and having trouble paying for medications and fees for appointments. Some insured patients experienced challenges affording copayments or having claims denied by the insurance company.

Several patients and providers mentioned that the severity of psychiatric symptoms hampered patients from attending appointments. One patient said, “When you live with depression and . . . sometimes when you wake up in the morning . . . life tells you, ‘I’m not going to walk out the door today.’” However, providers noted that seeing reductions in symptoms can be a motivator for patients to remain engaged in treatment.

Patients described other needs, such as family obligations, work, or general health, taking priority over mental health appointments. Several patients reported difficulties related to unreliable child care, inflexible work schedules, or insecure housing. For many patients, these multiple factors were longstanding barriers to engaging in care. One provider said, “They’re usually in overwhelming situations. Their goal is mostly just to make it day to day.” To work with patients on such barriers, some providers allowed family members or children to attend sessions.

Provider-Level Barriers and Facilitators

The two themes at the provider level centered on the connection between the patient and the provider as well as on establishing and maintaining contact.

Patient-provider connection.

Providers facilitated patient engagement through building rapport, fostering comfort, and showing compassion. For patients who talked with an outpatient mental health provider in the ED or soon after, this early connection supported transitions of care. Patients noted that providers made them feel that they were not alone and that someone understood what they were going through. Patients said that they felt comfortable opening up about their challenges when providers took time with them, were nonjudgmental and caring, and connected them to resources. Peer specialists mentioned how the ability to relate to their patients’ experiences was key in building positive relationships.

Establishing and maintaining connections.

Providers described difficulties connecting with patients in the ED or soon after and then maintaining contact with patients. One provider said, “Most of the people I call, the phone’s cut off, or the voice mail’s not set up, and then once I do get a hold of [the patient], they’ll make appointments and then they don’t show up.” Of the patients who came for an appointment after ED discharge, many did not return for subsequent visits. One patient said that remembering appointments was difficult “because I have a mental fog a lot, and I’m taking care of my dad who is going through dementia and changed jobs and all that kind of stuff, so I’ve got a lot going on, so to get that reminder call from [the CMHC] was very helpful.” Counselors said that high caseloads limited the amount of time they had to contact patients, whereas peer specialists generally had more flexibility.

Health Care System–Level Barriers and Facilitators

The main themes related to health care system–level factors were coordination between the ED and CMHC, scheduling of outpatient appointments, and available health care resources.

ED to CMHC coordination.

Providers stated that communication between the ED and CMHC supported transitions of care, but this interaction does not always happen. Providers noted that ED staff did not always notify the CMHC that a patient was in the ED, although most patients received appointments at the CMHC before ED discharge. A couple of the CMHC providers described spending some of their time in the ED to help make the process “run a lot smoother” by making appointments and communicating with other CMHC providers. Providers noted that CMHCs try to get patients in quickly, usually within 3 days of discharge. Some clinics have walk-in appointments for patients coming from the ED.

Managing clinic appointments.

After patients enroll at the CMHC, both patients and providers said that subsequent appointments were generally easy to set up. One patient noted, “All I have to do is call, and within a day or so I’ll have an appointment.” Providers said that it can be challenging for patients to navigate all of their appointments. They described the balance between connecting patients coming from the ED with needed treatment and resources, which may involve seeing a psychiatrist, therapist, peer support specialist, and case manager as well as the potential of overwhelming patients.

Health care resources.

Providers reported that CMHCs have sliding scales and, often, medication-assistance programs to help uninsured patients who experience challenges paying for treatment. Providers noted that patients are often unaware of the resources available at the CMHC.

Discussion

This study provides an in-depth examination of the barriers and facilitators to engaging in outpatient mental health care after discharge from the ED. The findings underscore the significant and multilevel challenges experienced by people with psychiatric disorders. Although some barriers in this sample aligned with previous research on general barriers to attending appointments, such as financial difficulties and stigma, we found other barriers and facilitators that appear to be especially significant for people with psychiatric disorders who transition from the ED to community-based outpatient care. These barriers and facilitators include a greater importance of transportation, the relationship with providers, and the connections between the ED and clinic. Additionally, barriers tended to cluster together. For example, transportation issues, lack of insurance, and financial difficulties commonly converged for some patients.

Transportation and financial difficulties were the main barriers to transitions and engagement in care. For patients with low income and no reliable transportation, Medicaid’s nonemergency medical transportation benefit provides a way to access mental health care, although these programs vary within and between states (21–23). Transportation did not emerge as a main barrier in other studies among people who perceived an unmet need for mental health treatment (13, 14, 24). Therefore, it may be particularly important to connect people with mental illness who come to the ED with transportation resources.

Similar to other research on barriers to receiving treatment (13, 14, 24), patients and providers in our sample described financial barriers to engaging in care. People with serious mental illness are more likely than people with milder conditions or people with no mental illness to be uninsured or to be enrolled in Medicaid (24). Despite an increase in rates of insurance for people with psychiatric disorders since Medicaid expansion under the Affordable Care Act (25), patients may still face challenges in accessing care because of a recent decline in the likelihood of psychiatrists accepting new patients with Medicaid (26). Providers in our sample described efforts to ensure that patients were aware of resources, such as sliding scale fees and medication-assistance programs. Because patients described financial barriers to care, tailored educational efforts may need to occur in both the ED and CMHC.

At the provider level, both patients and providers discussed the importance of the patient-provider relationship in facilitating transitions and engagement in care. Patients in our study indicated that connecting with CMHC providers while still in the ED or soon afterward facilitated their transition to the CMHC. After arrival at the CMHC, compassion and rapport between the patient and provider were key elements to supporting engagement. These findings align with other qualitative research on continuity of care for people with psychiatric disorders, which has identified similar characteristics of beneficial patient-provider relationships, including mutual trust and respect, providers working to make patients feel welcome and seen, and providers involving patients in decision making about their treatment (27–30). The providers in our sample also described the need to gauge a patient’s readiness to engage in different services and help them to navigate the system. Establishing rapport can be particularly challenging in emergency room settings, where service users often report having their symptoms ignored and that EDs are used because of a lack of outpatient services (16). Bringing mental health staff from local clinics onsite can help establish rapport and linkages to outpatient aftercare during this critical period.

At the health care system level, the findings indicate the importance of clear channels of communication between EDs and CMHCs. Strengthening policies to promote coordination across psychiatric care settings could contribute to lower ED readmission rates (31). Effective approaches for transitions of care from inpatient to outpatient psychiatric settings include telephone follow-up, transition or care managers, home visits, and peer support (32–34). These approaches could be applied to transitioning from the ED. For example, some mental health providers in our sample spent time in the ED to facilitate the patients’ transition to the CMHC and to promote communication between the EDs and CMHCs. Limited empirical research has focused on transitions from the ED to outpatient care, and findings are mixed. Boudreaux et al. (35) showed that a CMHC outreach team that met with patients in the ED and followed up after discharge improved attendance at outpatient appointments. Stergiopoulos et al. (36) found that a case management program connecting patients in the ED to community-based services reduced subsequent ED visits, although not significantly; in addition, a case management program did not influence the number of primary care visits among frequent ED users with mental illness or substance use disorders. Future research is needed to further examine strategies for outreach or case management that effectively support transitions of care.

People with psychiatric disorders experience challenges that may be difficult for an individual clinic to address. Patients and providers in this sample noted that patients’ transitions and engagement in care were hampered by availability and cost of transportation, challenges affording treatment, and a variety of competing needs, including family responsibilities, poor general health, and insecure housing. Additionally, these barriers commonly clustered together and represented longstanding issues. These challenges align with other research describing the complex health and social services needs of people with psychiatric disorders who frequent the ED (37). Our findings underscore the need to consider and address social determinants of mental health as precipitators of ED visits (38).

The strengths of this study are the inclusion of the perspectives of mental health providers, certified peer specialists, and patients across the eight sites of the parent study. With 45 interviews of patients and providers, saturation within the data was reached, allowing us to gain a deeper understanding of the themes (39). However, the findings from this qualitative study should be seen in light of several limitations. Participating patients and providers were part of one state mental health system, and patients in different settings may experience a different constellation of barriers to care. The providers who agreed to participate may have different experiences with or perceptions of engagement with care compared with those who did not want to participate or could not participate because of scheduling conflicts. The patients who agreed to participate may have different experiences compared with individuals who declined or who unavailable for follow-up from the parent study.

Additionally, given that the parent study offered care management in addition to usual care services, participants may have different experiences compared with individuals who did not receive any care management through the parent program. Patient interviews occurred 6–12 months after the ED visit that connected them with the study; therefore, the results may be subject to recall bias about experiences during and soon after the ED visit. Information about where the participants received care was limited to the information available in the parent study; thus, it is possible that some participants received care outside of the state mental health system. Finally, we were unable to address several engagement-related issues related to access, including cultural factors, the match between provider and patient, and the match between the treatment offered by the provider and the patient’s preferences. Future research should examine how these factors affect patients’ experiences in ED settings and their role in facilitating engagement after discharge.

Conclusions

Patients with a psychiatric disorder experience barriers and facilitators at multiple levels when engaging in mental health care after ED discharge. Our findings suggest that improving transitions from the ED to outpatient follow-up will require multilevel strategies that address patients’ complex health and life circumstances, bolster the relationship with providers in the ED and outpatient settings, and improve coordination between care settings.