New Strategies for Psych Care

The 15 inpatient and five emergency psychiatric beds that Robin Henderson oversees at St. Charles Health System had been filled since Sunday and, by Wednesday, there were no indications that the strain would ease soon.

At least six patients who needed inpatient care were being monitored in one of the emergency departments, says Henderson, a psychologist and director of behavioral health services at the Bend, Ore., organization. The nonprofit system owns, leases or manages four hospitals located just east of the Cascade Range.

"I have patients sitting all over the place waiting for psychiatric beds because we have none," Henderson said that February afternoon. "And, to make matters worse, there are no available psychiatric beds in Oregon right now."

But Henderson wasn't just grumbling about the struggle to meet mental health needs, a near-chronic pressure that only has intensified during the economic downturn. She's among a cadre of clinicians and hospital leaders around the country who are pioneering new ways to help patients, with the hope of providing better care with the same or fewer dollars. "We recognize that nobody is going to give us any more money, so we have to change the way that we deliver services," she says.

Shifting gears has led to, among other steps, the health system's involvement in a central Oregon pilot demonstration project that resulted in pooling Medicaid dollars for mental and physical treatment rather than artificially splitting the patient care (and the funding source) in two. In other regions of the country, mental health leaders are taking innovative steps to triage and treat mental health patients more effectively, with a particular focus on the influx through the ED doors. For example, in Oklahoma City, mystery shoppers were tapped to gain some honest feedback. "We found out that we had a system that wasn't very functional," says Larry Phillips, the program manager in behavioral medicine for 686-bed St. Anthony Hospital. (See sidebar.)

For hospitals that provide mental health services, recent years have proven to be the proverbial best of times and worst of times. On one hand, mental health care is finally getting some bottom-line respect in the form of the federal mental health parity law and last year's passage of the health reform law.

But on the other hand, those promising signs hit at a time of tremendous economic strain for both patients and state funding sources. Mental health clinicians who were interviewed report a notable increase in anxiety, depression, substance abuse problems and other emotional ripple effects from the recent and, in some areas of the country, ongoing economic stress.

Meanwhile, strapped state budgets have resulted in sometimes hefty mental health cuts, even before the most recent round of headlines about deficits. From fiscal 2009 to fiscal 2011, a combined total of more than $2 billion was eliminated from state mental health spending, according to survey data presented by the National Association of State Mental Health Program Directors Research Institute at a February congressional briefing. Deeper cuts are expected in 2012, according to the National Alliance on Mental Illness.

How can board members possibly plan amid this sea of flux? Think strategically, but with your local area's needs and resources in mind, hospital leaders and health care experts say.

Approaches that might look promising in central Oregon could make little sense when applied to Manhattan, says Rebecca Chickey, director of member relations for the American Hospital Association's section for psychiatric and substance-abuse services. In other regions of the country, some hospitals might not have a psychiatric unit or an on-site psychiatrist.

Stalling on planning isn't an option either, despite uncertainties like health reform, she says. "I think hospital leaders are going to have to start implementing [initiatives] now and many, many of them are."

Local Pressures

Michael Zieman, director of behavioral health services for 445-bed Memorial Hospital in Gulfport, Miss., knows firsthand how economic pressures can flow through the emergency department doors.

About six months after Hurricane Katrina, a surge in substance-abuse and mental-health problems became apparent, he says. Of particular concern, he says, "we saw an increase in suicide attempts."

In 2006, Memorial Hospital documented 400 attempts, nearly twice the number identified the prior year. Then, until 2010, the annual rate was at or near 300 attempts annually. Substance-abuse difficulties and mental-health symptoms also flared, including depression and anxiety, some of which understandably persist today. "Each time a hurricane comes into the Gulf, people get all stirred up again and rightfully so," Zieman says.

Then the Gulf oil spill occurred in the spring of 2010 amid an ongoing national recession, devastating the local fishing and tourism community. When people are out of work, they postpone medical care, including treatment for mental health symptoms, Zieman says. "We have been on psychiatric saturation multiple times in November, December and January," he said early this year.

When the hospital declares psychiatric saturation, paramedics try to find a psychiatric bed elsewhere in the state, he says. "The reality is that they may also bring the patients to us, because there is nowhere else to take them."

Nationally, the number of inpatient psychiatric beds continues to decrease. By 2009, a total of slightly more than 114,000 beds were available in acute care and freestanding psychiatric hospitals, compared with 160,645 in 1995, according to American Hospital Association data.

As state and local legislators struggle with budget shortfalls, one frequently voiced worry from hospital leaders involves the impact of those cuts on community-based transitional programs and support services, Chickey says. These types of programs provide critical support once someone is discharged from a substance-abuse or mental-health inpatient bed, she says.

"With an appendectomy, you can go home and stay in bed for a couple of days and you're fine," she says. But as state and local communities tighten their fiscal belts, Chickey says, "the ability to discharge behavioral health patients in a manner that's consistent with the patient needs is being more and more challenged."

Integrating Resources

For trustees, there might be some opportunities, driven in large part by the anticipated shift in health care reimbursement, says Diane Stewart, a board member for Hawaii's Kahi Mohala Behavioral Health, a freestanding psychiatric hospital that's part of Sacramento-based Sutter Health.

Better treatment of the depression associated with heart-bypass surgery, for example, could pay off over the long haul as the nation's health system moves toward bundled payments through such structures as accountable care organizations, she says. Trustees can play a key role in education and development of related programs.

"We have got to convince people that in a stand-alone financial analysis, psychiatry is rarely ever going to make money," Stewart says. "It's probably never going to break even. The real value of psychiatry in integration is in the cost savings on the other end of care."

In central Oregon, Henderson long has been singing a similar tune. But a recent analysis of frequent ED users confirmed how staggeringly expensive it can be to treat medical versus mental-health symptoms separately.

The analysis, which looked at patients who had used one of the system's EDs at least 10 times in the prior year, identified a mixture of substance abuse, depression and other mental-health issues intertwined with physical maladies. Nearly 80 percent of the patients were insured and slightly more than half had Medicaid coverage, according to health system data.

But under the state's Medicaid program, the Oregon Health Plan, medical treatment is funded separately from mental-health treatment. So there was no way for local mental-health clinicians to know if one of their patients was revolving through the ED doors, Henderson says. "You have this huge disconnect where you have this person who has incredible anxiety and they are coming to the emergency room repeatedly because they believe they are having a heart attack," Henderson says.

The resulting analysis, conducted in conjunction with state officials and PacificSource Health Plans, found that 100 of those frequent users cost the health care system in total—including hospital, physician care and insurance coverage—$66,000 annually a piece on average. "If I can impact 10 of those people in a year and change their health care trajectory, I could reclaim half a million dollars," Henderson says.

In response, St. Charles Health System has become more aggressive about identifying so-called frequent fliers, taking steps to pair them early on with a case manager, a psychologist and possibly a community health worker. An individualized plan is created not only to better coordinate a patient's medical and mental-health treatment, but also to delve into why he or she relies on the ED rather than a primary care provider.

This spring, the hospital system received its first results for the initial group of frequent fliers, 102 of whom are covered by Medicaid and 46 of whom have another type of insurance or no coverage. Henderson described the data, which compared before and after the emergency department initiative, as "really hopeful."

Emergency visits by the 102 Medicaid patients had dropped by more than half, from a total of 393 during the first three months of 2010 to 176 visits for the same patients during the first quarter of 2011. Usage by non-Medicaid patients also declined during the same three-month period from 176 to 96.

Some of the solutions have been nonclinical, says Ryan Dix, a psychologist based at the system's Pioneer Memorial Hospital in Prineville. "A lot of times it can be something as simple as helping a person to get child care in order to make it to their [doctor] appointments rather than going to the emergency room, because they waited and couldn't get a sitter."

The demonstration project is part of a larger effort involving three counties to create a public-private partnership called the Central Oregon Health Council. The goal for the authority, which includes St. Charles Health System and a cross-section of community health services, is to oversee and help guide the planning, regulation and purchase of health care services, including the ability to receive public funds. (For more detail, see cohealthcouncil.org.)

In January, the physical and mental health Medicaid funding for those three counties was merged under one existing health plan, with the intention of moving oversight for all under one entity by 2012.

Fast-tracking Patients

Better coordination between medical and mental-health clinicians also can ease the logjam in the ED, as an initiative in Stockton, Calif., determined.

Leaving psychiatric patients waiting too long in an ED risks exacerbating their symptoms, says Paul Rains, R.N., president of St. Joseph's Behavioral Health Center, a freestanding psychiatric hospital that serves seven nearby acute care hospitals. "They tend to get worse and even act out," he says. "It presents a problem for security for the emergency departments."

But those patients still need to be assessed for underlying medical problems before they can be transferred to St. Joseph's. That medical clearance was taking eight hours or longer, amid the other crises that emergency clinicians were handling, Rains says.

So Rains, working with nearby hospitals, developed a medical review process for psychiatric patients to identify more rapidly any medical issues, as well as to complete related laboratory work. For its part, St. Joseph's committed in early 2010 to make sure someone was in the ED within two hours to evaluate the patient. St. Joseph's achieved that goal within the first few months and has remained on track since then, according to Rains. "I think we definitely have impacted the issue of medical clearance because very rarely do we turn someone right back around and send them back to the hospital," Rains says.

Hospitals with on-site psychiatric departments also could adopt a similar approach, to balance the vital medical clearance while providing patients with mental-health intervention more quickly, he says.

But fast-tracking efforts depend on the availability of an inpatient bed. During that February stretch at St. Charles when the psychiatry unit was overbooked, Dix was called to assist a young man experiencing his first psychotic break.

The emergency physician had recommended admission. But even if a bed could have been found, it's typically preferred to avoid the psychological strain of hospitalization, if feasible, Dix says. Since Dix was on-site, he could assess the young man and develop an alternate plan, one that included an outpatient mental health appointment the next morning. An antipsychotic prescription was filled and the patient returned home with family members.

Henderson, who first described the young man's situation, points to the on-site expertise of Dix as illustrative of how earlier intervention can assist both the patient and the health system. "We might be able to divert that [hospital] admission and keep that family whole," she says. "The longer we divert that admission, the better this kid's chance of lifetime success is.

"I don't want to ever build another psychiatric unit over here. Nobody wants to be in an inpatient psych unit."

Charlotte Huff is a writer in Fort Worth, Texas