Split-Flow Model Streamlines Emergency Mental Health Care

How can efficiencies in the emergency department free up beds for critical mental health needs?

For the last several years, researchers in the Children’s Hospital Colorado Pediatric Mental Health Institute have collected data to understand the mental health struggles youth in Colorado face so they could begin moving toward solutions. One major area of concern was the emergency department (ED), which is often the first stop for kids in crisis. What they found pointed to a need for significant improvements, says process improvement specialist Rebecca Colley, MBA.

“We found that patients who presented with a behavioral health concern stayed in our EDs four times longer than patients who presented with a medical concern,” she explains. That resulted in an average length of stay around 18 hours, regardless of the severity of their presenting issue.

That’s because at intake, every single patient who visited a Children’s Colorado ED for behavioral health was scored using only the traditional Emergency Severity Index (ESI) scale, in which 1 is the most severe and 5 is the least. This score was developed for medical concerns but was being applied to mental health as well.

Regardless of the details of their case, each child seeking behavioral health care in the ED was immediately given a score of 2. This would trigger a safety protocol designed for severe cases, such as suicidal ideation. During this process, kids are taken to a room where they change into paper scrubs and are separated from their belongings to ensure their safety. This lengthy process is valuable for kids who are at risk of harming themselves or others, but for those whose concerns were less acute, it was an overuse of resources and time.

Finding the split-flow model

Seeking solutions, the team looked at how peers across the industry were managing the same problems and resource strains.

“We knew that we could do crisis care better, so we did a national search, and we talked with a lot of our peers, conducted a lot of research and analyzed white papers,” Colley says. “What we came up with is a multilevel model of care. We knew that kiddos entering our emergency department needed multiple levels of care, and in Colorado, we were lacking the ability to provide that type of care in the same capacity that we have for physical healthcare.”

By pulling bits and pieces from multiple approaches, Colley and colleagues were able to create a process tailored to the specific needs of Colorado’s pediatric population. They started with a new severity scoring index, developed by a team in Australia. This acuity score for behavioral health operated on a scale of one through five, similar to the ESI. This had already been adopted at Cohen Children’s Medical Center in New York to great success. The team there shared that they had combined this new acuity score with a split-flow pathway.

Colley and her team took a similar approach, creating two tracks for kids who visited the ED for behavioral health care. They launched a pilot of this method in October 2024 and have since used initial learnings to iterate, improve and continue evaluating.

It works like this: Upon arrival at the ED, kids are triaged and receive an ESI score and a behavioral health score. Based on those scores, providers can dial in the level of care they need. If it’s determined that they are medically stable and their behavioral health needs are not severe enough to warrant a full crisis screening, they can proceed through the low-acuity track.

This system helped the team free up beds and time to devote to higher-acuity patients.

“What we're seeing is that we aren't using those beds for these lower-acuity kids, and so we're able to then get kids with higher-acuity needs — those with suicidal ideation or a suicide attempt — into those really limited resources quicker,” says Jamie Winter, Director of the Pediatric Mental Health Institute.

Creating efficiency and saving precious time

Staffed by behavioral health clinicians, the low-acuity track allows patients who might simply need resources, outpatient referrals or evaluation for minor concerns to move through the system much quicker, thus freeing up more time for kids who need to follow the traditional high-acuity approach.

For example, on the very first day the new model was officially rolled out, a patient came in seeking help. They had an outpatient appointment scheduled for later in the month but realized that they would run out of their prescription medication before having the opportunity to meet with their new provider. Because their mental health could not afford a lapse in medication, they sought care in the ED.

“Before we had split-flow, we would not have been able to fill this gap, and they would've just gone through that one-size-fits-all, high-acuity visit where they would've been with us for hours,” Colley says. “This patient was able to get their medication refilled, were only with us for two and a half hours, and then were safely discharged back to their community and successfully reestablished care.”

This is typical of the low-acuity patient experience these days, she adds. Average length of stay for patients like this one is down to just 2.8 hours, and overall length of stay has dropped to 14 hours from 18. This means that patients on the low-acuity track save an average of 11 hours. What’s more, patients now have new clinics and programs they can access after discharge to help them.

One such program is the new Crisis Clinic. After low-acuity patients are safely discharged from the ED, the team connects them with the clinic, if appropriate, to ensure they have a follow-up appointment scheduled before leaving the emergency department.

Another new program supporting kids and families is the Care Transitions Team, which was designed to provide assistance with navigating the mental health system after an emergency department visit or inpatient hospitalization.

Together, these new approaches to care are improving team member experience, relieving burdens on patients and families, and connecting children to the right care at the right time.

“Healthcare systems are always looking to magically create more beds, and we can't always build our way out of it,” Colley says. “It's about creating capacity through efficiencies, and you create efficiencies by having the right workflows, the right resources, and the ability to send patients where they need when they need it.”