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Behavioral Health Assessment and Referrals in the Emergency Department (ED)

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The following processes have been implemented at two EDs in rural Appalachian New York State.

Criteria for handoff to BHAO

Upon screening a patient in the ED, the triage nurse determines whether a handoff to the Behavioral Health Assessment Officer (BHAO) is needed. The triage nurse contacts the BHAO when the patient presents with:

  • Age 12 and over
  • Suicidal and/or violence risk or concerns
  • Self-harm behaviors
  • Acute mood, anxiety, or psychotic disorder
  • A substance use disorder (SUD)
  • Significant adjustment disorder including adjustment to an existing medical condition
  • Behavioral problems interfering with medical care or safe disposition

Assessment by BHAO

The BHAO does an assessment that includes suicide and violence risk, SUD, mental health, and social history and arrives at recommendations for management and follow up. Following SUD assessment, the BHAO may coordinate with nursing staff, who would conduct screenings/ratings scales such as a Clinical Institute Withdrawal Assessment (CIWA), Drugs of Abuse Urine (DAU) screen, and Clinical Opiate Withdrawal Scale (COWS).

BHAO determinations may include:

  1. What immediate interventions are needed to initiate care or ensure safety of the patient and others?
  2. Does the patient need to be admitted to inpatient treatment?
  3. Does the patient need a linkage to treatment for mental health and/or SUD?
  4. Does the patient need a linkage to a residential program?
  5. Should family or supports/peers be involved in disposition?

In many cases, the BHAO makes recommendations for treatment without input from a psychiatrist. When needed in complex situations, the BHAO consults with a psychiatrist through telehealth. (See our tool on BHAO Telepsychiatry Workflow.)

Referral to SUD treatment program

BHAOs provide referrals to area SUD treatment organizations, connecting patients with peer advocates at those organizations.

  • If the patient screens positive for SUD risk, the BHAO provides education on the benefits of treatment.
  • The BHAO provides a naloxone kit and training as needed.
  • If the patient requests treatment, the BHAO contacts the treatment program to coordinate a handoff.
  • A peer advocate meets with the patient in the ED or connects with them soon after. Transportation for the patient is coordinated.
  • If an intake assessment time is not available right away and a patient is in opioid withdrawal, an ED provider may begin the buprenorphine induction process prior to the patient’s enrollment in the treatment program.

See our tool on Emergency Department Workflow for Mental Health and Substance Use Disorder.

When BHAO is unavailable

The ED should establish procedures for when the BHAO is not on-site for assessment, naloxone distribution, referrals, and other tasks. The workflow in this case may include:

  • The triage nurse screens for SUD risk.
  • If the patient screens positive, an ED provider in collaboration with nursing staff does assessment for withdrawal and risk. The provider may begin the buprenorphine induction process.
  • The triage nurse coordinates with the SUD treatment program to arrange a meeting for the patient with a peer advocate.
  • The BHAO follows up with patients during their next shift.

If needed while the BHAO in unavailable, telehealth consultation with a psychiatrist is focused on a specific question rather than broader behavioral health assessment.

Psychiatric transfers

If the patient meets criteria for transfer to inpatient psychiatric care, the BHAO assists with the process by:

  • Initiating the call to the transfer center or appropriate psychiatric facility
  • Compiling and faxing required legal documents for involuntary commitment
  • Coordinating/communicating updates with the treatment team


The BHAO’s role in the discharge process includes:

  • Clearing patients presenting with low or chronic risk (may also be carried out by psychiatrist)
  • Offering to connect patients to outpatient services and, if they accept, making those connections
  • Completing After Visit Summaries; providing patients and families with copies of follow-up appointments and other treatment recommendations