Lost Among Us: Mentally ill languish in ERs awaiting scarce psychiatric hospital beds
Nurses, doctors and other staff bustle around a claustrophobic, U-shaped pod, weaving past hospital beds and carts that line the walls.
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Armed officers pass, burly men maneuvering through the thin space, a buzz of radio traffic trailing behind them, reminding everyone of their much-needed presence here.
About this series
The mentally ill are under scrutiny and pressure like never before. Mental health budgets have been slashed. State inpatient beds are at historic lows. Emergency rooms and jails are the new front lines of care. And gun-control debates focus on the mentally ill.But there is promise for change. State funding may increase. Research shows these illnesses are based in flawed physiology, not character flaws. And many who suffer are openly challenging stigmas.The Post and Courier will examine these issues in a series of stories over the coming months. In this installment, we look at local emergency rooms where the severely mentally ill are arriving sicker and staying longer than ever before.
A technician sits in the hallway, eyes on constant vigil for patients’ suicide attempts or aggression.
Cuts to S.C. Department of Mental Health beds
Total general inpatient beds:*2000 1,036 2001 9342002 7722003 6802004 6132005 5992006 6062007 6182008 5962009 5502010 5232011 5222012 495* Includes beds at the S.C. State Hospital, Crafts-Farrow State Hospital, William S. Hall, G. Werber Bryan, Patrick B. Harris and forensics beds at Columbia Regional Care CenterSource: S.C. Department of Mental Health
Yet this is not a psychiatric hospital.
By the numbers
62%Nationwide drop in inpatient psychiatric beds since 1970.53 millionMental health-related ER visits nationwide per year.70%ER directors nationwide who report psychiatric patients waiting in ERs more than 24 hours for beds. 10%Directors who report ER psychiatric patients waiting more than a week for beds.Source: Emergency Physicians Monthly
It is part of MUSC’s emergency department.
State mental health funding cuts
The S.C. Department of Mental Health has endured cuts to its state and Medicaid funding even as more people need its services.Fiscal year 2008 State appropriations ......$220 millionMedicaid $81 million*Total operating budget $369 millionFiscal year 2013 (projected)State appropriations $154 millionMedicaid $69 millionTotal operating budget $345 million* DMH receives other funds, including revenue from Medicaid disproportionate share, veterans’ care in state nursing homes, grants, contractual services, Medicare and private insurance.
There are no locks on doors. The lone bathroom is the only suicide-proof room.
There is no shower for patients here; nobody is supposed to stay long enough to need one. Yet increasingly, they do.
Psychiatric “boarders,” as they’re called, often dominate this pod intended for short-term, acutely ill patients. At times fully half of MUSC’s ER, among the region’s busiest, has been filled with psychiatric boarders.
These are folks at imminent risk of harming themselves or others and need emergency inpatient psychiatric treatment.
Yet there are not enough beds for them all.
So they wait in local ERs, often for hours and days.
Across South Carolina and the nation, growing numbers of severely mentally ill residents are languishing in ERs waiting for sharply reduced numbers of statewide inpatient psychiatric beds.
They wait, often handcuffed and shackled in hospital beds, guarded by police or security.
The S.C. Hospital Association has declared it a “hidden crisis.”
Of MUSC’s roughly 50,000 ER patients a year, nearly 12 percent are mentally ill today. They are arriving sicker and staying longer than ever before.
Dr. Christine Carr, medical director of MUSC’s Emergency Medicine, has watched her ER become a front line of mental health care, though her training is not in psychiatry.
“I’ve been here 18 years, and I’ve never seen the patients sicker,” Carr said. “There’s just no light at the end of the tunnel.”
Three of her staff were assaulted by mentally ill patients in the past few weeks. One staffer is pressing charges.
“It is a risk,” Carr said. “It’s scary to be a small woman in a room with a very mentally ill patient. We’re all on edge about who will be next.”
Three critical issues are fueling the problem statewide — closing of inpatient psychiatric beds, funding cuts to the state Department of Mental Health and overall increased demand for mental health care.
Psychiatric patients aren’t the only ones who suffer.
People in the midst of suicidal, violent or delusional breakdowns can severely disrupt other ER patients and families, including children and the elderly, who arrive with traditional emergencies such as car-wreck injuries, chest pain and strokes, ER officials said.
The challenge is no different across the street from MUSC at Roper Hospital.
“It’s one of our greatest problems in health care today,” said Wanda Brockmeyer, director of Roper St. Francis Healthcare’s emergency services. “Yet it is the least talked about, gets the least amount of money and gets the least amount of attention.”
And up Interstate 26 at Trident Health System’s hospitals in Summerville and North Charleston, nearly half of the 800 mentally ill patients discharged from its ERs last year waited at least 24 hours to transfer to psychiatric hospital beds.
Of those, 73 waited in an ER for three full days — or more.
“Typical ER patients stay one to three hours,” Trident Health System CEO Todd Gallati said. “(Psychiatric) patients are staying as long as four to five days.”
To address the growing problem, Trident Medical Center has asked the state for permission to add 18 inpatient behavioral-health beds and hired a psychiatrist to staff its ER.
“State-run beds are just not an option anymore,” Gallati said.
Birth of a crisis
Just a few decades ago, more than 3,000 people lived in massive hospitals on the state Department of Mental Health’s sprawling campus in Columbia.
Birth of a crisis
Those committed had little hope of ever leaving.
But modern medications and therapies, and improved understanding of mental illness, meant few folks now require lives locked in “lunatic asylums.”
Reform was born: Save money and improve lives by releasing patients from hospitals back into their local communities. Being closer to home would mean being closer to family, friends and other support. It would mean greater freedom and quality of life for thousands.
So along with states nationwide, South Carolina mental health officials embarked on a massive closing of hospital beds. In the past decade alone, DMH has closed more than half of its remaining general inpatient psychiatric beds.
In 2000 the state had 1,036 of these beds. Last year it had 495.
Today, the 181-acre campus sits mostly abandoned, its hulking, red brick buildings looming as shells of memories, broken windows and peeling paint. Private developers are planning its reuse.
To serve folks closer to home, DMH opened assisted-living-style group homes and bolstered community services. For instance, in the Charleston area four group homes offered the mentally ill a structured transition from hospitals to independence.
But then the economy tanked. Two things happened:
DMH faced enormous cuts in state and Medicaid funding.
And hospitals saw a spike in people suffering “episodic” mental health disorders such as major depression and suicide risks following job losses, long-term unemployment and other traumatic events.
“More people are competing for already very limited resources that are shrinking,” said Eileen McLaughlin, senior social worker at MUSC’s Institute of Psychiatry.
Meanwhile, funding cuts filtered down to local mental health centers.
Today, the Charleston Dorchester Mental Health Center operates with one-third less money and half the staff it had in fiscal 2004.
Berkeley County’s center operates with 22 percent less money and 39 percent fewer staff than a decade ago.
“Everything has been pushed to the community. But we don’t have the funding in the community,” DMH Director John Magill said.
All four of the Charleston area DMH-run group homes, called community residential care facilities, closed. Now, a lack of community options is leaving more people without care, said Tom Robinson, business development manager of MUSC’s Institute of Psychiatry and a suicide prevention activist.
“They essentially go untreated and get too far down the pike,” Robinson said. “If the system were working, patients wouldn’t be going to the emergency department for treatment.”
The new front lines
In many ways, Charlestonians are lucky.
The new front lines
Local mental health centers here have more community resources than most other regions to help keep people out of ERs, including the state’s only mobile crisis unit and an RV that takes care to rural areas.
Charleston also is home to MUSC’s Institute of Psychiatry, a large public inpatient hospital on the downtown campus.
Yet on one recent morning the Institute of Psychiatry’s roughly 100 general adult beds were full. Ten people were waiting for beds across the street in MUSC’s ER, each in the midst of a psychiatric crisis.
They include everyone from a person who has become so delusional he could jump off a bridge if the voices say so, to someone who has attempted suicide, to someone who has become violent at home.
Psychiatrist Baron Short is director of the institute’s adult general psychiatry unit, among his many other hats. Recently, he tried to remember the last time a bed on his unit sat empty for a day.
He thought he could recall once in the past year.
“In 2006, it wasn’t like that. It wasn’t uncommon to have multiple days within a month. There wasn’t this urgency,” Short said.
The ER influx plays a huge role.
From 2006 to 2008, about 500 adult patients a year went from MUSC’s ER to beds in its Institute of Psychiatry. That has tripled to more than 1,500 a year today.
Overall, 80 percent of patients admitted to the Institute of Psychiatry now come from emergency rooms statewide, according to institute data.
Mentally ill patients with private insurance have easier times finding beds at private hospitals, such as Palmetto Behavioral Health. Charleston and Dorchester county residents who are poor, involuntarily committed and lack Medicaid can apply for money to pay for beds, including private ones, through the local mental health center.
The rest wait longer.
While they wait, they drive up costs. ERs are among the most expensive areas to get care.
Yet of those who go from ERs to the Institute of Psychiatry, one-third are uninsured — and unlikely to pay.
Who picks up those costs? Everyone else, in insurance premiums, co-payments and other areas.
While they wait, the mentally ill in crisis also take up ER beds and staff needed for acute emergency patients.
And the mentally ill don’t get the inpatient care they need.
“We can keep them nourished and medicated, when necessary, and protect them,” Roper’s Brockmeyer said. “But as far as truly treating them, we aren’t prepared for that in the emergency department.”
No money to help
Many mental health experts agree: South Carolina needs more inpatient psychiatric beds.
No money to help
“We have gone way too far,” Brockmeyer said. “Many of the folks turned out from institutions really were safer and better off before.”
Top officials at DMH agree there’s a need for more state-run beds. But that isn’t the whole solution.
Private hospitals also have closed psychiatric beds. Some, including Trident, want to reverse that trend.
However, most severely ill people still don’t need long-term hospitalization.
They need the group homes, day programs and other less-intensive options that were the cornerstones of reform.
“The philosophy is still sound. Very few people need to spend long periods of time in the hospital,” DMH Deputy Director and General Counsel Mark Binkley said. “Some of these folks just need a lot of structure — to be reminded about hygiene, reminded and encouraged to stay on medications.”
With more local options, patients could be discharged from hospitals sooner, freeing up space. And if they had more structured places to go, fewer would wind up in ERs again, officials said.
“You can discharge people from the hospital all day long, but if they just wind up back in a week, what have you really accomplished?” Binkley asked.
One of Charleston’s top advocates for the mentally ill agrees.
Too often, seriously ill folks go to hospitals in their worst conditions and a week later are discharged home, said Joann Monnin-Debevec, president of the National Alliance on Mental Illness’ Charleston area chapter.
“They get them patched up, put some meds into them and send them out the door. Then, they are back in three months,” Monnin-Debevec said. “They don’t have the support. That’s why there is such a revolving door.”
After discharge, patients often leave with medication and an outpatient appointment.
Yet many also need a middle ground, something between being hospitalized in crisis and returning directly home or to the streets, Monnin-Debevec said.
MUSC’s Carr agrees. “You can’t just send the acutely psychotic patient home because they are 50 percent better. There is nowhere for them to go.”
If they lack that, where do patients wind up?
“This is not really about the ER,” Carr said. “It is about what is happening before and after.”
Much of it comes down to money.
Today, DMH operates with the same state appropriations it received 25 years ago. The purchasing power of that money is half what it was, Binkley said.
The agency also weathered large cuts in Medicaid payments, its other major funding source, even as more people became uninsured and unable to pay for their care.
DMH is likely to see its second consecutive state budget increase this year, but that will not pay for new expenses like hospital beds or group homes.
A man sits handcuffed on his bed in MUSC’s ER, alone with his thoughts.
A few doors down, two women lie in beds, their room shrouded in dark silence, although it is a brilliant midday outside.
A staff member in the hall speaks on her phone: “I have a candidate for seclusion …”
Her patient, agitated and waiting, just threw a chair.
It’s not unusual for one-third of this ER — or 12 beds — to be occupied by psychiatric patients.
They languish, some suicidal, others psychotic. About one in five is an “escalation risk.” It takes just one volatile patient to set off the others.
Those who turn dangerous are taken down ER halls full of staff, paramedics and the sick or injured, and on to the seclusion room.
Inside its heavy door sits a square, concrete-block room with a rectangular block for a bed. Nothing else.
Patients can calm down in here — or be restrained for everyone’s safety.
A camera watches. So does a staff member outside.
An empty applesauce container and drink cup remain from the last occupant.
“We are doing the best we possibly can,” Carr said.
Yet, she added, it is ideal for no one.