Form CMS-10487 Key Informant Interview Protocols

ATTACHMENT B
KEY INFORMANT INTERVIEW PROTOCOLS

MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION (MEPD)
INTERVIEW GUIDE: MEPD PROJECT DIRECTOR
Round of Site Visit:
Site Visit Dates:
State:
Date of MEPD Implementation:
Informant(s) Name: [Using notes from the initial interview conducted during fall 2012, insert name, title, and role
and responsibilities in the demonstration]
Informant(s) Title:
Informant(s) Contact Information:
Date of Interview:
Time of Interview:
Interviewer:
Note taker:
I.

Introduction
Thank you for agreeing to speak with us. As you know, Mathematica Policy Research is evaluating the
Medicaid Emergency Psychiatric Demonstration for the Centers for Medicare & Medicaid Services (CMS)
through its Center for Medicare and Medicaid Innovation (CMMI). The evaluation will determine whether
and to what extent using Medicaid funding to provide care for adults in private institutions for mental
disease (IMDs) impacts service use, quality of care, and Medicaid costs.
We are speaking with you to learn about changes in the state’s role in administering the demonstration and
associated costs, evolving contextual factors affecting psychiatric emergency and inpatient care in the state,
and implementation facilitators and challenges.
We will be taking notes during the interview and would like to audiotape our discussion to ensure that we
have captured your comments accurately. The audio recording will not be shared with anyone outside of the
project team and will be destroyed at the conclusion of the study. Is this okay with you?
Do you have any questions before we get started?

II.

Role and Responsibilities
1.

III.

Has your role and responsibilities changed since we last spoke on [insert date of fall 2012 interview]?
If so, please describe.

Program Design
2.

What specific service improvements are being made as part of the demonstration?

3.

Please describe your procedures for monitoring the demonstration.
3a. How is this working?

4.

What monitoring procedures have been most useful?

5.

What suggestions do you have about demonstration monitoring for other states?

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IV. Access to Inpatient Psychiatric Care
Next, I’d like to talk about access to care.
6.

How does access to inpatient psychiatric care for Medicaid beneficiaries experiencing a psychiatric
emergency compare to access for those beneficiaries before the demonstration?
PROBE:

V.

Has access to inpatient psychiatric care increased or decreased? Why or why not?

7.

Have there been any changes in patient enrollment estimates since we last spoke on [insert date of
fall 2012 interview]?

8.

If there has been a change in patient enrollment, what accounts for this change?

Boarding Time in ER and General Hospital Scatter Beds
I’d like to shift the discussion to boarding in ERs and general hospital scatter beds.
9.

Can you discuss the extent of emergency room boarding in the state?

10. Can you discuss the extent of psychiatric boarding in general hospital scatter beds in the state?
11. How does psychiatric boarding time in ERs for patients with psychiatric emergencies compare to
boarding times for psychiatric emergencies before the demonstration?
PROBE:

Has boarding time increased or decreased? Why?

12. Is this different for Medicaid beneficiaries?
13. How does psychiatric boarding time in GH scatter beds for patients with psychiatric emergencies
compare to boarding times for psychiatric emergencies before the demonstration?
PROBE:

Has boarding time increased or decreased? Why?

14. Is this different for Medicaid beneficiaries?
VI. Referral and Admission
Next, I’d like to talk about referral and admission, stabilization, and discharge planning.
15. How do you verify that the patients admitted to the demonstration are suicidal, homicidal, or a
danger to themselves or others?
16. How do you verify that the participants in the demonstration are enrolled in Medicaid at the time
they are admitted to the IMD?
VII. Stabilization [Insert stabilization assessment requirements identified in the operating plan and/or interview
notes]
17. How are you ensuring that IMDs are adhering to stabilization assessment requirements?
18. How is this process going?
18a. What is going well?
18b. What would you like to be done differently?
19. How do stabilization criteria in your state differ from the criteria used for the demonstration?
VIII. Length of Stay
20. How does the average length of stay for patients enrolled in the demonstration compare to21 the
average length of stay for patients not participating in the demonstration? (e.g., Medicaid

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beneficiaries with psychiatric emergencies who are admitted to the public IMDs, general hospitals, or
alternatives.)
IX. Discharge Planning
21. What kinds of changes, if any, have occurred regarding post-discharge follow up procedures for
Medicaid beneficiaries as a result of the demonstration?
22. How are you monitoring discharge planning for demonstration patients and for non-demonstration
psychiatric patients at IMDs?
23. Are you experiencing challenges in monitoring discharge planning? If so, please describe.
24. Have IMDs reported challenges to discharge planning? If so, please describe.
25. Under the demonstration, has the proportion of Medicaid beneficiaries with psychiatric emergencies
discharged from participating IMDs to community-based residences changed?

X.

PROBE:

How has it changed?

PROBE:

To where are demonstration patients being discharged most frequently?

Cost
26. Can you describe the effect the demonstration has had on costs to the state?
27. How has care provided by private IMDs impacted state Medicaid costs under the demonstration?
28. How have dollars saved by receiving the federal match been invested by the state?
29. What is your perspective on cost-shifting due to the demonstration?
30. What were the administrative costs to fully implement the demonstration (e.g., for staffing or
making changes to the physical environment)?

XI.

Context
Next, I’d like to talk about the context in which the demonstration is operating.
31. How are psychiatric emergency services provided in the state?
31a. How many psychiatric emergency providers are in the state?
32. Can you discuss the extent to which there is a shortage of inpatient psychiatric beds in the state?
33. How has the demonstration influenced state hospital bed capacity (e.g., crowding, waiting lists)?
34. Can you describe the levels and types of investments the state is making in community-based
behavioral health services (e.g., Assertive Community Treatment programs, mobile crisis treatment
teams, partial hospitalization programs)?
35. Can you describe the availability of psychiatric step-down and outpatient services in your state?
35a. Are psychiatric step-down and outpatient services reimbursed by Medicaid?
35b. If not, how are these services reimbursed?
36. Have there been any changes in mental health service delivery that could affect the demonstration
(e.g., closure of facilities, new IMDs opening)?
37. Is the state involved in other initiatives that could influence the demonstration (e.g., Institute for
Behavioral Health Care Improvement Collaborative)?
38. Are you aware of any state-level initiatives that may be changing the incidence of psychiatric
emergencies and access to services for patients experiencing a psychiatric emergency?

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39. Are there any planned changes in mental health services at the state level that could affect the
demonstration (e.g., change in payment structure)?
40. How will the 2014 Medicaid expansion influence the demonstration (e.g., expenditures and
population served)?
XII. Outcomes
I’d like to conclude the interview by talking about outcomes of the demonstration.
41. What are your thoughts about potential short-term effects of the demonstration?
42. What do you think are the two most important changes, if any, resulting from the demonstration?
43. What do you hope the demonstration will do?
XIII. Closing
That completes the questions we have for you today.
• Is there anything we should have asked about but didn’t?
• Do you have anything you would like to tell us, or questions you would like to ask us?
Thank you again for taking the time to speak with us. We appreciate and value your input.

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MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION (MEPD)
INTERVIEW GUIDE: MEPD IMD STAFF MEMBER
Round of Site Visit:
Site Visit Dates:
Facility Name:
Facility State:
Date of MEPD Implementation:
Informant(s) Name: [Note if informant is IMD point of contact interviewed in fall 2012.]
Informant(s) Title:
Informant Contact Information:
Date of Interview:
Time of Interview:
Interviewer:
Note taker:

I.

Introduction
Thank you for taking the time to speak with us. We are from Mathematica Policy Research, an independent
research firm contracted by the Centers for Medicare & Medicaid Services (CMS) through its Center for
Medicare and Medicaid Innovation (CMMI) to evaluate the Medicaid Emergency Psychiatric Demonstration.
The three-year demonstration allows eligible, private institutions for mental disease (IMDs) in participating
states to receive federal Medicaid reimbursement for adults ages 18 to 64. The purpose of the
demonstration is to make inpatient care more accessible to adult Medicaid beneficiaries with psychiatric
emergency medical conditions. The evaluation will determine whether and to what extent using Medicaid
funding to provide care for adults in private IMDs impacts service use, quality of care, and Medicaid costs.
We are speaking with you to learn about how care is provided in [insert name of IMD] In particular; we are
interested in understanding how the referral and admission, stabilization and discharge planning processes
differ for Medicaid beneficiaries as a result of the demonstration.
We will be taking notes during the interview and would like to audiotape our discussion to ensure that we
have captured your comments accurately. The audio recording will not be shared with anyone outside of the
project team and will be destroyed at the conclusion of the study. Is this okay with you?
Do you have any questions before we get started?

II.

Role and Responsibilities
1.

Please describe your role and responsibilities at [insert name of IMD].

2.

How long have you been in this role?

3.

How long have you worked at [insert name of IMD]?

4.

Are you aware that [insert name of IMD] is participating in the Medicaid Emergency Psychiatric
Demonstration?

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[Interviewer: If informant is not aware of the demonstration, reword all questions referring to the ‘demonstration’
as the ‘date of implementation.’ See example in Q5 below.]
III.

Program Design
5.

What specific service improvements are being made as part of the demonstration?

[Interviewer: If informant is not aware of the demonstration, reword this question as: What specific service
improvements are being made since [insert month, year of demonstration implementation]]?
6.

What organizational changes were made to the facility as a result of the demonstration (e.g.,
staffing changes, changes in staff responsibilities)?

[Interviewer: Ask Q7 and Q8 only if informant is IMD point of contact, a hospital administrator and/or is familiar
with the monitoring of the demonstration.]
7.

What are your perceptions about the state’s procedures for monitoring the demonstration?

8.

What would you change about the state’s monitoring procedures?

IV. Access to Inpatient Psychiatric Care
I would like to discuss access to care.
[Interviewer: If informant is not aware of the demonstration, reword all questions referring to the ‘demonstration’
as the ‘date of implementation.’]
9.

How does access to inpatient psychiatric care for Medicaid beneficiaries experiencing a psychiatric
emergency compare to access for those beneficiaries before the demonstration?

PROBE: Has access to inpatient psychiatric care increased or decreased? Why or why not?
10. How has the mix of patients in this hospital changed since implementing the demonstration on
[insert date of implementation]?
11. [Ask only if informant is aware of the demonstration.] Are you noticing any trends in the
participation of a particular sub-group of populations eligible for the demonstration (e.g., trends by
age, race, gender, Medicaid eligibility status)? If so, please describe these trends.
12. [Ask only if informant is aware of the demonstration.] Are you having challenges with
implementing patient eligibility criteria? If so, please describe these challenges.
[Interviewer: ask Q13 and Q14 only if the informant is the IMD point of contact we spoke with in fall 2012. Contact
state lead to obtain patient enrollment estimates if not known.]
13. Have there been any changes in patient enrollment estimates since we last spoke on [insert date]?
14. If there has been a change in patient enrollment estimates, what accounts for this change?
15. [Ask only if informant is aware of the demonstration.] How has bed capacity changed as a result of
the demonstration?
PROBE: Has the facility added beds, opened additional units, or started staffing beds that were previously not
used?
V.

Boarding Time in ER

[Interviewer: If informant is not aware of the demonstration, reword all questions referring to the ‘demonstration’
as ‘date of implementation.’]

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Now I’d like to talk about the amount of time patients spend in the ER or intake department prior to
admission.
16. Does this hospital have an ER or a place where someone comes (for example, an intake or
assessment department) because they are experiencing a psychiatric emergency condition? Is so,
please describe. [Obtain during site visit planning.]
17. Before the demonstration, did this facility ever have to board Medicaid patients in the ER or
intake/assessment department while awaiting admission to a hospital for psychiatric emergency?
18. Has this changed since the demonstration was implemented in [insert date of implementation]?
19. If this has changed since the demonstration, on average how long does a patient with a psychiatric
emergency currently wait in the ER or intake/assessment department once it has been decided that
psychiatric hospitalization is needed?
20. Is this different for Medicaid beneficiaries?
21. Has this changed since the demonstration began in [insert date of implementation]?
PROBE: Have wait times in the ER or intake/assessment department increased or decreased since the
demonstration began? Why or why not?
VI. Referral and Admission
[Interviewer: If informant is not aware of the demonstration, reword all questions referring to the ‘demonstration’
as the ‘date of implementation.’]
I’d like to shift the discussion to referral and admission to this hospital.
22. What is the primary source of referral for patients to this hospital?
22a.[Ask only if informant is aware of the demonstration.] Is that the same referral source for
demonstration patients? If not, what is the primary referral source for demonstration patients?
23. What are other sources of referral for patients to this hospital?
23a. [Ask only if informant is aware of the demonstration.] Are the other referral sources the same
for demonstration patients? If not, what are the other sources of referral for demonstration patients?
24. How has your relationship with other sources of referral for admission of patients with psychiatric
emergencies changed as a result of the demonstration?
25. How does the referral process since the demonstration began differ from what you were doing
before the demonstration?
26. [Ask only if informant is aware of the demonstration.] What are your primary methods for
identifying patients for the demonstration?
VII. Stabilization
Next, I would like to discuss procedures for stabilizing patients.
[Interviewer: If informant is not aware of the demonstration, reword all questions referring to the ‘demonstration’
as the ‘date of implementation’.]
27. Please describe your stabilization assessment procedures.
28. How does the stabilization assessment under the demonstration differ from what you were doing
before the demonstration?
29. Are you experiencing any challenges adhering to the stabilization assessment requirements?

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30. What types of treatments do patients receive while in this hospital?
PROBE: What types of therapies and modes are offered, for example, psychotherapies (CBT, interpersonal
therapy, and behavioral therapy), psychoeducation and individual and/or group psychotherapy, or other
therapeutic treatments?
31. How does this treatment compare to the treatment received by non-Medicaid beneficiaries with
psychiatric emergencies treated in this hospital?
32. How does treatment of psychiatric emergencies differ from treatment provided to patients not
experiencing a psychiatric emergency?
VIII. Length of Stay
[Interviewer: Ask Q33 and Q34 only if time permits.]
33. What is the average length of stay for patients in this hospital?
PROBE: For example, people with psychiatric emergencies with payment sources other than Medicaid and
people without psychiatric emergencies.
34. [Ask only if informant is aware of the demonstration.] What is the average length of stay for
patients enrolled in the demonstration?
IX. Discharge Planning
Now I’d like to talk about discharge planning and post-discharge care.
Interviewer: If informant is not aware of the demonstration, reword all questions referring to the ‘demonstration’
as the ‘date of implementation.’
35. Could you please describe the hospital’s discharge planning procedures?
35a. [Ask only if informant is aware of the demonstration.] Are the discharge planning procedures
the same for demonstration patients? If not, how do they differ?
36. How does the discharge planning process differ now from what you were doing prior to the
demonstration?
37. How has the quality of discharge planning changed under the demonstration?
PROBE: Has the quality of discharge planning improved, worsened, or stayed the same?
38. How are patients at your hospital involved in discharge planning?
PROBE: How does patient involvement (or lack of) impact the patient’s discharge experience?
39. Is this different than how patients were involved in discharge planning before the demonstration?
40. How does the amount of time staff spend developing discharge plans now compare to the amount
of time staff spent on discharge planning for Medicaid beneficiaries prior to the demonstration?
41. Under the demonstration, has the proportion of Medicaid beneficiaries with psychiatric emergencies
discharged from your hospital to community-based residences changed?
PROBE: How has the proportion discharged from your hospital to community-based residences changed?
42. Under the demonstration, has the level of detail included in discharge plans changed?
PROBE: How has the level of included detail changed? What is included?
43. To where is the majority of patients discharged?
PROBE: For example, home, group home or other structured setting, jail, or patients are homeless.

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44. [Ask only if informant is aware of the demonstration.] To where is the majority of demonstration
patients discharged?
45. What proportion of patients are discharged outside of the local area?
45a. [Ask only if informant is aware of the demonstration.] What proportion of demonstration
patients are discharged outside of the local area?
46. What types of aftercare services are provided to patients?
46a. [Ask only if informant is aware of the demonstration.] What types of aftercare services are
provided to demonstration patients?
47. Where do the majority of patients typically receive aftercare services?
47a. [Ask only if informant is aware of the demonstration.] Where do the majority of
demonstration patients typically receive aftercare services?
48. Could you please describe the post discharge follow up procedures for Medicaid beneficiaries?
49. [Ask only if informant is aware of demonstration.] What kinds of changes, if any, have occurred
regarding post-discharge follow up procedures for Medicaid beneficiaries as a result of the
demonstration?
X.

Cost
I’d like to ask next a few questions about cost.

Interviewer: ask Q50 – Q52 only if informant is IMD point of contact, a hospital administrator, and/or is aware of
the demonstration.
50. Can you describe the effect the demonstration has had on costs to your hospital?
51. How has the care provided under the demonstration impacted Medicaid costs?
52. What, if any, were the administrative costs to the hospital to fully implement the demonstration
(e.g., for staffing or making changes to the physical environment)?
XI. Context
I’d like to talk about the availability of mental health services.
53. What types of psychiatric step-down and outpatient services are available for patients?
53a. [Ask only if informant is aware of demonstration.] What types of psychiatric step-down and
outpatient services are available for demonstration patients?
54. Are psychiatric step-down and outpatient services reimbursed by Medicaid?
54a. If not, how are these services funded?
55. Please describe the working relationship your facility has with psychiatric step-down or outpatient
providers.
56. Have there been any changes in mental health service delivery that could affect the demonstration
(e.g., closure of facilities, new IMDs/hospitals opening, changes in availability of community-based
services)?
57. Are you aware of any local-level events or initiatives that may be changing the incidence of
psychiatric emergencies and access to services for patients experiencing a psychiatric emergency?

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XII. Outcomes
I’d like to conclude by talking about outcomes of the demonstration.
58. What are your thoughts about potential short-term effects of the demonstration?
59. What do you think are the two most important changes, if any, resulting from the demonstration?
60. What do you hope the demonstration will do?
XIII. Closing
That completes the questions we have for you today.
• Is there anything we should have asked about but didn’t?
• Do you have anything you would like to tell us, or questions you would like to ask us?
Thank you again for taking the time to speak with us. We appreciate and value your input.

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MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION (MEPD)
INTERVIEW GUIDE: MEPD GH STAFF MEMBER
Round of Site Visit:
Site Visit Dates:
Facility Name:
Facility State:
Date of MEPD Implementation:
Informant(s) Name:
Informant(s) Title:
Informant(s) Contact Information
Date of Interview:
Time of Interview:
Interviewer:
Note taker:
I.

Introduction
Thank you for taking the time to speak with us. We are from Mathematica Policy Research, an independent
research firm contracted by the Centers for Medicare & Medicaid Services (CMS) through its Center for
Medicare and Medicaid Innovation (CMMI) to evaluate the Medicaid Emergency Psychiatric Demonstration.
The three-year demonstration allows eligible, private institutions for mental disease (IMDs) in participating
states to receive federal Medicaid reimbursement for adults ages 21 to 64. The purpose of the
demonstration is to make inpatient care more accessible to adult Medicaid beneficiaries with psychiatric
emergency medical conditions. The evaluation will determine whether and to what extent using Medicaid
funding to provide care for adults in private IMDs impacts service use, quality of care, and Medicaid costs.
We are speaking with you to learn about how care is provided in [insert name of GH]. In particular, we are
interested in understanding how care is provided to Medicaid beneficiaries experiencing a psychiatric
emergency and the process of referring these individuals for inpatient psychiatric treatment.
We will be taking notes during the interview and would like to audiotape our discussion to ensure that we
have captured your comments accurately. The audio recording will not be shared with anyone outside of the
project team and will be destroyed at the conclusion of the study. Is this okay with you?
Do you have any questions before we get started?

II.

Role and Responsibilities
1. Please describe your role and responsibilities at [insert name of GH].
2.

How long have you been in this role?

3.

How long have you worked at [insert name of GH]?

4.

Are you aware of the state’s participation in the Medicaid Emergency Psychiatric Demonstration?

[Interviewer: If respondent is not aware of the demonstration, reword all questions referring to the demonstration
as the date of implementation.]

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III.

Program Design
5.

Have you seen any service improvements since [insert name(s) of participating IMD(s)] began the
demonstration?

PROBE: For example, changes in procedures for identifying available inpatient beds, ER diversion, use of peer
supports in ER, use of mobile crisis team.
IV. Access to Inpatient Psychiatric Care
Next, I would like to discuss access to care.
6.

Have you observed any changes in the number of patients being admitted to non-psychiatric units of
this hospital for treatment of a psychiatric emergency?

PROBE: Has it increased or decreased? Why?
7.
V.

If a change was noted in either direction, how has this change influenced the quality of care
delivered?

Boarding Time in ER
Now I’d like to talk about the amount of time patients spend in the ER prior to admission.
8.

In your experience, how long do patients admitted to your unit after experiencing a psychiatric
emergency wait in the ER before being admitted?

[Interviewer: If long waits are reported, ask why.]
9.

Has this changed since [insert start date of demonstration in state]?

10. If a change was observed, what factors do you think account for the change?
VI. Referral and Admission
I’d like to shift the discussion to referral and admission to this hospital.
11. Please describe the process for admitting patients with psychiatric emergencies from the ER to nonpsychiatric units of this hospital.
12. Have there been any changes in the admission process recently?
12a.If so, what has changed? Why?
VII. Stabilization
13. Next, please tell me about the types of treatments patients experiencing psychiatric emergencies
receive while in non-psychiatric units of this hospital.
14. How is stabilization of the psychiatric emergency assessed?
15. When does the assessment begin?
16. How often are stabilization assessments conducted?
17. Is there anything you would like to see done differently in how patients with psychiatric emergencies
are stabilized on non-psychiatric units of this hospital?
VIII. Length of Stay
18. What is the average length of stay for psychiatric patients admitted to non- psychiatric units of this
hospital?

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19. On average, how long do psychiatric emergency patients stay in non-psychiatric units of this hospital
while awaiting admission to a psychiatric unit or psychiatric hospital?
IX. Discharge Planning
Now I’d like to talk about discharge planning and post-discharge care.
20. Please describe the discharge planning process for psychiatric patients admitted to non-psychiatric
units of this hospital.
21. When does discharge planning begin?
22. Who is involved in developing a discharge plan for psychiatric patients?
23. How are psychiatric patients receiving care from non-psychiatric units in your hospital involved in
discharge planning?
24. To where are psychiatric patients treated in non-psychiatric units of your hospital being discharged
most frequently?
25. What types of aftercare services are provided to psychiatric patients?
X.

Context
I’d like to talk about the context in which the demonstration is operating.

Interviewer note: ask Q26 – 31 only if hospital has a psychiatric unit.
26. How does having an inpatient psychiatric unit affect the extent of psychiatric boarding in your ER
and non-psychiatric units?
27. What are the referral sources for admission to the psychiatric unit of your hospital?
28. Have the sources of referral to the unit changed since the demonstration was implemented [insert
date of implementation]?
29. What types of patients are served by the psychiatric unit?
30. What impacts has the demonstration had on the hospital’s psychiatric unit, if any?
PROBE: Are they more likely to serve Medicaid beneficiaries or other patients with psychiatric emergencies?
31. Has the average length of stay or discharge planning process changed since implementing the
demonstration on [insert date of implementation]?
32. Have there been any changes in mental health service delivery that could affect the demonstration?
PROBE: For example, closure of facilities, new IMDs opening, changes in how psychiatric emergencies are
handled in your hospital or community, changes in availability in community-based services?
33. Are there any planned changes in mental health services at the state level that could affect the
demonstration?
PROBE: For example, change in payment structure?
XI. Closing
That completes the questions we have for you today.
• Is there anything we should have asked about but didn’t?
• Do you have anything you would like to tell us, or questions you would like to ask us?
Thank you again for taking the time to speak with us. We appreciate and value your input.

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MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION (MEPD)
INTERVIEW GUIDE: MEPD ER STAFF MEMBER
Round of Site Visit:
Site Visit Dates:
Facility Name:
Facility State:
Date of MEPD Implementation:
Informant(s) Name:
Informant(s) Title:
Informant(s) Contact Information:
Date of Interview:
Time of Interview:
Interviewer:
Note taker:

I.

Introduction
Thank you for taking the time to speak with us. We are from Mathematica Policy Research, an independent
research firm contracted by the Centers for Medicare & Medicaid Services (CMS) through its Center for
Medicare and Medicaid Innovation (CMMI) to evaluate the Medicaid Emergency Psychiatric Demonstration.
The three-year demonstration allows eligible, private institutions for mental disease (IMDs) in participating
states to receive federal Medicaid reimbursement for adults ages 21 to 64. The purpose of the
demonstration is to make inpatient care more accessible to adult Medicaid beneficiaries with psychiatric
emergency medical conditions. The evaluation will determine whether and to what extent using Medicaid
funding to provide care for adults in private IMDs impacts service use, quality of care, and Medicaid costs.
We are speaking with you to learn about how care is provided in [insert name of ER] In particular; we are
interested in understanding how care is provided to Medicaid beneficiaries experiencing a psychiatric
emergency and the process of referring these individuals for inpatient psychiatric treatment.
We will be taking notes during the interview and would like to audiotape our discussion to ensure that we
have captured your comments accurately. The audio recording will not be shared with anyone outside of the
project team and will be destroyed at the conclusion of the study. Is this okay with you?
Do you have any questions before we get started?

II.

Role and Responsibilities
1.

Please describe your role and responsibilities at [insert name of ER].

2.

How long have you been in this role?

3.

How long have you worked at [insert name of ER]?

4.

Are you aware of the state’s participation in the Medicaid Emergency Psychiatric Demonstration?

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[Interviewer: If respondent is not aware of the demonstration, reword all questions referring to the
demonstration as the date of implementation].
III.

Program Design
5.

Have you seen any service improvements since [insert name(s) of participating IMD(s)] began the
demonstration?

PROBE: For example, changes in procedures for identifying available inpatient beds, ER diversion, use of peer
supports in ER, use of mobile crisis teams.
IV. Access to Inpatient Psychiatric Care
Next, I would like to discuss access to care.
6.

How often do individuals experiencing a psychiatric emergency seek treatment in this ER?

7.

Please describe how you work with individuals experiencing a psychiatric emergency.

[Interviewer: Ask Q8 only if this hospital has a psychiatric unit.]
8.

I understand that this hospital has a psychiatric unit. Do you contact the unit to determine bed
availability?
8a. If the psychiatric unit is not contacted, please explain why.

9.

Which facilities do you contact for inpatient care for patients with a psychiatric emergency?

10. Are the facilities you contact the same facilities you contact for Medicaid beneficiaries?
PROBE: Why or why not? Is there a particular order in you contact hospitals?
11. What is your experience with the rate at which patients with psychiatric emergencies are accepted
by these hospitals?
11.a Is the acceptance rate different for Medicaid beneficiaries?
V.

Boarding Time in ER
Now I’d like to talk about the amount of time patients spend in the ER prior to admission.
12. On average, how long does a patient with a psychiatric emergency currently wait in the ER once it
has been decided that psychiatric hospitalization is needed?
13. Are wait times different for Medicaid beneficiaries?
14. Has this changed since [insert start date of demonstration in state]?
15. If a change was observed, what factors do you think account for the change?

VI. Referral and Admission
I’d like to shift the discussion to referral and admission of patients experiencing a psychiatric emergency to
psychiatric hospitals.
16. How do you determine whether someone in the ER is suicidal, homicidal, or a danger to themselves
or others?
17. How do you determine whether someone with a psychiatric emergency is in need of inpatient
psychiatric hospitalization?

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18. Have you noticed any changes since [insert start of demonstration in state] in how patients who
present with a psychiatric emergency in your ER are admitted?
PROBE: Do you contact a different person to assess the patient’s level of need? Are the verification
process or eligibility criteria different? Has the timing of the verification process changed?
19. Have there been any changes in the types of patients admitted since [insert start of demonstration in
state]?
PROBE: Were there any patients not admitted for inpatient care that you felt should have been?
20. Has the admission process changed under the demonstration?
VII. Stabilization
21. Next, please describe how patients experiencing a psychiatric emergency are stabilized in the ER.
22. Have these processes changed since the demonstration was implemented?
VIII. Cost
[Interviewer: ask Q23 only if informant is a hospital administrator and/or is aware of the demonstration.]
23. What, if any, were your administrative costs to fully implement the demonstration (e.g., for staffing
or making changes to the physical environment)?
IX. Context
I’d like to talk about the context in which the demonstration is operating.
24. To what extent is psychiatric boarding an issue in your ER?
25. Is your hospital or department involved in other initiatives that could influence the demonstration
(e.g., ER diversion programs)?
26. Have there been any changes in the community that have affected the number of individuals with a
psychiatric emergency who present in the ER?
27. Does the [insert name of IMD] participation in the demonstration change how you refer patients?
PROBE: For example, are you more inclined to contact IMDs first?
X.

Outcomes
I’d like to conclude the interview by talking about outcomes of the demonstration.
28. What are your thoughts about potential short-term effects of the demonstration?
29. What do you think are the two most important changes, if any, resulting from the demonstration?
30. What do you hope the demonstration will do?

XI. Closing
That completes the questions we have for you today.
•
•

Is there anything we should have asked about but didn’t?
Do you have anything you would like to tell us, or questions you would like to ask us?

Thank you again for taking the time to speak with us. We appreciate and value your input.

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