Psych Units Shutting Doors
February 27, 2009
Friday, February 27, 2009
Psych units shutting doors
By Karen Augè
The Denver Post
Posted: 01/25/2009 12:30:00 AM MST
Updated: 01/25/2009 03:52:30 PM MST
Susie Hall, RN and Jen Szczepanski BSN,RN Interim Nurse Manager of the Denver Health Psychiatric Emergency Ward in the nurses station. (The Denver Post | Joe Amon)
The pills were never going to make Carrie Epps' depression go away. Their job was merely to keep it stuffed deep inside, where it couldn't hurt her.
For a while, they worked.
And then, suddenly, they stopped. So Epps took more pills — enough, she hoped, to stop the depression forever.
But she didn't die. Instead, she woke up in the emergency room. Doctors pumped her stomach and kept her from dying. But saving her life would mean watching her day and night. It would mean eight days in the psychiatric ward at the old University of Colorado Hospital.
That was three years ago. If Epps' depression emerged now, there would be no stay at University Hospital. This month, the hospital became the latest in a long list of
Click on image to enlarge. facilities that have closed their doors to inpatient psychiatric care.
Hospitals in Colorado and across the country are closing psychiatric units at a breathtaking pace. CU says its decision was about providing the best care to all patients. But across the country, the disappearance of psychiatric units is a trend driven less by changing treatment philosophies for the mentally ill than by money.
No one seriously advocates a return to the past, when the mentally ill were sent off to hospitals and asylums, often never to be seen or heard from again.
At the same time, there are those in crisis who need to be hospitalized, at least briefly.
For those people, the options are shrinking, so much so that those who treat the mentally ill fear a crisis could result from the growing shortage of beds.
Certainly the fallout from that shortage is already being felt — in emergency departments and jails, where the mentally ill often sit, warehoused and untreated, at taxpayers' expense. And it is felt, most painfully, by the mentally ill themselves, and those who care about them.
With the beds at CU gone, the metro area will have about 380 general adult psychiatric beds — a drop of nearly two-thirds since 1990.
About 40,000 mentally ill people show up in Colorado emergency rooms each year, statistics show. Of those, about 40 percent need hospitalization.
"I'm really very concerned about where those patients are going to go. They're going to be flooding emergency rooms," said Glenn Most, a psychologist and director of Exempla West Pines, a 38-bed psychiatric unit adjacent to Lutheran Medical Center in Wheat Ridge.
Most said there may be room for some of them in his facility — or there may not.
"On some days we have the capacity to take all comers. Other days it seems every psych hospital in town is full. It's bad now, and I'm afraid it's going to get worse."
Beth Lonegran, director of emergency services for the Mental Health Center, which serves Boulder and Broomfield counties, said the ripples from CU's closure will be widely felt.
"University has been one of the few places where the medically indigent have been able to go, particularly if they have any medical conditions."
No room for new patients
In November, hospital officials, outpatient treatment providers, patient advocates and others met to try to figure out ways to cope with a situation they say threatens to become a full-blown crisis.
Some relief will come from growth in the number of hospitals that treat seniors exclusively. Beds for seniors are actually on the rise, thanks in part to changes in Medicare rules that make treating senior citizens more economically viable.
Carrie Epps says she would not be alive if she hadn't been hospitalized at the University of Colorado Hospital after attempting suicide several years ago. (The Denver Post | Joe Amon )the shortage of beds is a problem nationwide, it is especially acute in Colorado: In December, the American College of Emergency Physicians ranked the state 50th of 50 states and the District of Columbia in the number of inpatient psychiatric beds.
The survey found Colorado has 11.8 psychiatric beds for every 100,000 people, while nationwide the average was 30.
The shortage of beds is bad enough that in November the state hospital at Pueblo had to turn away patients for nearly a week.
The hospital, which has eliminated more than 60 percent of its beds since 1990 because of budget cuts, had no choice, said Liz McDonough, spokeswoman for the state Department of Human Services, which oversees state hospitals.
"The adult population
Click on image to enlarge was close to capacity, and there were concerns about safety and treatment," she said.
It's not the first time the hospital has been full.
"It is not common, but it does happen," McDonough said.
In part, the shrinking number of inpatient psychiatric beds is by design. Beginning in the late 1960s, the horrific, often squalid institutions of the past gave way to treatment focused on recovery and giving the mentally ill the means and medications to lead normal lives outside institutions.
Money to care for them was supposed to follow those patients, but too often it didn't.
Inpatient mental-health care, meanwhile, is more and more a money-losing proposition.
"The psychiatric end of the business just isn't very financially viable," Lonegran said.
Officials at University Hospital say money did not drive their decision to stop providing inpatient care: The hospital simply needed more medical beds, said Dr. Greg Stiegmann, the hospital's vice president for clinical affairs.
"We were consistently having 15 to 17 patients who were being boarded in the emergency department because there were no available beds for them," he said.
If money were the concern, Stiegmann said, the hospital wouldn't have built a psychiatric unit when it moved in 2007 from its old Denver location to its new Aurora home.
"We knew we'd be running this unit at a bit of a loss."
Although the 21-bed unit was often 90 percent full, operating it cost University about $1.7 million in the 2007-08 fiscal year, he said.
The university hopes to build a new outpatient clinic in the old Fitzsimons Army Hospital on its Anschutz campus that will have the capacity for 20 patients more than its current outpatient clinic can serve.
CU has committed $50,000 toward the $150,000 cost and hopes to raise the remainder from donations.
The university also has committed $100,000 a year for three years to the Metro Crisis Triage Project's effort to establish call centers and crisis care facilities that would create a coordinated, 24-hour mental-health crisis network across the seven-county metro area.
Hospitals stuck with bills
CU is hardly the first hospital to close its psychiatric unit. Heather Cameron, director of the Triage project, said the group found at least eight hospitals that had closed units in the past decade or so, including Presbyterian/St. Luke's and St. Anthony Central.
St. Anthony's closed in 2005; that year, the unit lost $3 million, said David Thompson, who became the hospital's chief financial officer after the closure.
The loss didn't come because the unit's 29 beds sat empty. On the contrary, "It stayed full. There definitely was a demand," Thompson said.
What was missing was payment for the care.
"The majority of patients did not have insurance," Thompson said.
At Denver Health Medical Center, 960 adults were admitted for inpatient treatment in 2007. Of those, 55 had private insurance, said Dr. Robert House, behavioral health director at Denver Health.
In November, Dr. Patricia Gabow, Denver Health's chief executive, warned that the number of uninsured patients might force the hospital to cut services — including mental- health care — in the coming year.
With University and St. Anthony hospitals shuttering their units, Gabow worries that the strain of psychiatric care, especially for indigent patients, could stretch their resources to the breaking point.
The hospital recently added a 10-bed psychiatric emergency unit, and it operates a 44-bed adult inpatient psychiatric unit.
Even when patients have insurance, there is no guarantee against losing money taking care of them.
At St. Anthony, insurance "reimbursement rates just weren't up to par. They just didn't cover the cost," Thompson said.
Many insurers require hospitals to provide almost daily justification for continuing treatment, and even then limit what they will cover, Most said.
"We have to beg sometimes every day to keep a patient in the hospital," Most said. "We have staff dedicated to just that."
More help for the insured
Congress took what the psychiatry and hospital industries see as an encouraging first step toward remedying the disparity between regular medical care and psychiatric care in October, when it passed the financial bailout package.
Tacked onto that package was so-called mental-health "parity" legislation. The law, which takes effect in October, requires health plans that insure 50 or more people and already provide mental-health benefits to make that coverage equal to medical coverage.
"We're hoping that it will have an effect," said Carl Clark, executive director of the Mental Health Center of Denver.
Whatever effect it does have will come a bit late for Epps. She has health insurance but still owes $18,000 to hospitals that have treated her.
It's not uncommon for those who are as ill as Epps was to enter the health care system via dramatic, or public, routes.
"When people are (mentally) ill, they often go out into the public," Clark said. "They don't stay at home like people who have the flu or a cold."
They go out and maybe commit some minor crime, such as trespassing. Or they simply behave erratically enough to scare someone.
And then, police get called.
"The police have the choice of taking them to the emergency room or jail," Clark said.
Pacing in the office of her counselor at the Mental Health Center of Denver recently, Epps said the closing of so many psych units worries her.
But it doesn't surprise her.
"Mental health is always the first thing to go."
In the early part of this decade, the state cut millions from mental-health care, both in outpatient clinics and capacity at the two state hospitals.
Now, the economy is even more anemic than it was then.
"There's not a whole lot of room for anything else out there to be cut," said George del Grosso, executive director of the Colorado Behavioral Healthcare Council, a statewide association of community mental-health centers. "I just don't know what the future will bring."
Epps worries about that too.
To her, psychiatric wards are "scary places." She hated every minute she spent at University's. She also is grateful for every minute she spent there. "I would have killed myself otherwise. I would have figured out a way."
Karen Auge: 303-954-1733 or firstname.lastname@example.org
Where to find hospital care:
Key metro-area hospitals licensed to provide adult inpatient psychiatric treatment, including patients involuntarily committed:
• Boulder Community Hospital: 10 beds
• Centennial Peaks Hospital, Louisville: 30 beds
• Colorado Mental Health Institute at Fort Logan, Denver: 153 adult beds*
• Denver Health Medical Center: 44 beds
• Exempla West Pines, Lutheran Medical Center, Wheat Ridge: 38 beds
• Highlands Behavioral Health System, Littleton: 56 beds
• Porter Adventist Hospital, Denver: 35 beds
*Does not include beds for those committed through the criminal justice system