Hospitals struggling with mental-health caseloads

Those with psychiatric conditions require considerable management and 'a lot of ER time'

In designing a new emergency department last year, officials at Jameson Health System in New Castle, Lawrence County, made special provisions for patients with mental-health needs.

Three of the 30 new examination rooms were built for people in mental-health, or behavioral-health, crises. These rooms, bare except for beds and soothing murals, are located away from exits in a quiet corner of the rectangle-shaped department. The patients who use them are brought in by police or people who don't know how else to help.

"They use us as a last resort," said Sybil Rossi, a registered nurse and the hospital's patient care manager and program director for behavioral-health services.

Bobbi Bishop, a former patient, now helps others

Bobbi Bishop was a patient at Mayview State Hospital. Now she lives on her own with the help of mental health outpatient treatment. (Video by Julia Rendleman; 9/23/2013)

Community hospitals across the region are struggling to serve an influx of patients with severe and chronic mental illness. Some attribute the wave of complex cases to the December 2008 closure of Mayview State Hospital, which served the sickest, most violent patients from Allegheny, Beaver, Greene, Lawrence and Washington counties.

PG graphic: Occupancy rates at local psych units
(Click image for larger version)

"As far as I'm concerned, several counties made a deal with the devil when they closed Mayview," said Patton V. Nickell, chairman of psychiatry for the Allegheny Health Network.

State and county officials said they closed Mayview in the belief that people with mental illness deserve to live in the community, or the least restrictive environment possible.

But now, some of those with serious, persistent mental illness account for repeated visits to the emergency departments and repeated admissions to the inpatient psychiatric units of community hospitals, Dr. Nickell said.

Though planners of Mayview's closure may have envisioned building an outpatient treatment system strong enough to support people with severe mental illness, that hasn't materialized, said Joseph Cvitkovic, director of behavioral health care for Jefferson Regional Medical Center in Jefferson Hills.

After Mayview

A special five-part series

Sunday, Sept. 22:

Overview and portrait of former Mayview State Hospital patients.
Monday, Sept. 23:
Community hospitals struggle with mental-health caseloads.
Tuesday. Sept. 24:
Police, courts improvise to manage ill offenders
Wednesday. Sept. 25:
Housing a weak link in mental-health system
Sunday, Sept. 29:
The future of mental-health treatment

The local hospital has "become what Mayview was. That's what happened. We pick up the slack for that," he said.

Besides an increase in the severity of patients' illness, hospitals said they have:

• Repeatedly treated some patients who have difficulty managing serious illnesses in the community.

• Treated a growing number of violent patients.

• Kept some mental-health patients longer than medically necessary because of a shortage of beds in step-down programs or, because of the shortages, discharged patients to locations they considered safe but less than ideal.

• Taken a financial loss when insurers cut off payment for patients who stay longer than strictly necessary.

State and local officials disputed the impact of Mayview's closure.

Valerie Vicari, director of the Division of Western Operations for the state Department of Public Welfare's Office of Mental Health and Substance Abuse Services, said mental-health professionals in other parts of the state have seen an increasing severity of mental-health cases, partly because of complications from some patients' use of illegal drugs.

Pat Valentine, executive deputy director for integrated program services at Allegheny County's Department of Human Services, said hospitals could be feeling the impact of recent cuts to the state's medical assistance rolls. Because of the cuts, she said, people who once received mental-health care on a regular basis from outpatient providers now may be accessing it only on a crisis basis in hospitals.

Ellie Medved, vice president of ambulatory and crisis operations at Western Psychiatric Institute and Clinic of UPMC, said emergency department visits have been up in recent years. She said they've also been up at UPMC Mercy and UPMC McKeesport.

But she said various factors could be responsible, including last year's elimination of the state's general-assistance program. She said the program, which provided about $200 cash each month to tens of thousands of sick and disadvantaged Pennsylvanians, was used to buy medication, pay for housing and provide other stability.

Mary Fleming, CEO of Allegheny HealthChoices Inc., the agency that helped plan Mayview's closure, said hospital complaints about mental-health caseloads are nothing new.

"They complained before Mayview was closed, and they complained after Mayview was closed," she said.

Tip of the iceberg

For some hospitals, the closing of Mayview delivered a one-two punch.

Of the 305 patients discharged as part of the 2005-2008 closure process, 212 have been treated at community hospitals at least once for psychiatric reasons, said Allegheny HealthChoices.

John Bogdan, nurse-manager of the behavioral-health unit at Monongahela Valley Hospital in Washington County, recalled one former Mayview patient who bounced from one residential program to another because of behavior problems. After the man landed in the hospital, Mr. Bogdan said, "it took us two months to find a place that could meet his needs and take care of his behavior."

Former Mayview patients are the tip of the iceberg. Community hospitals also serve the wider population of mental-health patients who might be admitted to Mayview today if it still were open.

According to a study commissioned by Allegheny HealthChoices, occupancy rates of inpatient psychiatric units at hospitals in the five counties ranged from 98.4 percent in January 2010 to 81.6 percent in December 2011. The occupancy rate in January 2012, the last month included in the study, was 84 percent.

"There are beds available. It's very rare that there aren't," Ms. Fleming said.

Hospitals said it isn't the number of admissions that trouble them as much as the complexity of some patients' illnesses, some patients' need for repeated hospitalizations and the extra resources, such as 24-hour monitoring, needed to care for some.

Disruptive patients and expensive medical equipment can be a volatile mix, Mr. Cvitkovic said, noting such patients require considerable management and "a lot of ER time."

Yet hospitals are under pressure from The Joint Commission, a national accrediting organization, to move patients -- regardless of illness type -- through the emergency department in no more than four hours. Bret Coons, commission spokesman, said hospitals aren't being penalized for failing to meet the four-hour guideline. He said they're only being encouraged to streamline emergency department visits for patient comfort.

Jameson has placed a behavioral health liaison on call to help speed the discharge planning process for mental-health patients who come into the emergency department during nights and weekends. But it is risky to discharge a person too soon.

John E. Kidney of West Deer last year sued UPMC Mercy for releasing him prematurely. He had gone to the hospital in March 2010 with suicidal thoughts and was, his suit says, "a clear and present danger to injure himself or others."

The hospital released him in about 33 hours, and about 15 hours after that, Mr. Kidney was struck by a freight train in Sewickley Township. He sustained major injuries, said the suit, which accuses the hospital of negligence. In court papers, the hospital denied wrongdoing.

If admitted to a psychiatric unit, Dr. Nickell, Ms. Rossi and officials at other hospitals said, patients sometimes stay longer than medically necessary. That's because group homes, rehabilitation programs and step-down programs often are full and can't take patients the hospitals are ready to discharge.

"I can tell you this much: We don't have vacancies," said Lynne Loresch, executive director of Mental Health Association of Washington County, which has a 12-bed enhanced personal-care home and a 16-bed long-term structured residence in Bentleyville.

Dr. Nickell said some patients could wait as long as six months for a bed to open in an extended recovery program.

Kathe Niznik, a registered nurse and director of psychiatric and mental-health services at St. Clair Hospital in Mt. Lebanon, said her 26-bed unit, intended to treat patients for about a week, has been keeping some severely ill patients as long as three months because it can't find beds in step-down programs.

"They're not well enough to be out in the community. That's why we're referring them to extended acute care. They're basically stuck on our acute-care unit," she said.

Ms. Niznik said the hospital has found that the area's longer-term step-down programs aren't of sufficient duration. "We're just finding there is a group of patients who need longer structure and longer treatment than even six months," she said.

As do emergency departments, inpatient units sometimes struggle to manage an increasing number of disruptive and violent patients. Community hospitals aren't necessarily equipped to handle these patients.

"When you had Mayview, you had a forensics unit," Mr. Cvitkovic said.

An incident in Beaver County last year underscored the danger of mixing different types of patients on a psychiatric unit.

In July 2012, Gerald L. Rooney Jr., 82, a patient on the inpatient psychiatric unit at Heritage Valley Beaver, wandered into the room of Peter Kuchynsky, 58, a former Mayview patient with schizophrenia. When Kuchynsky forcibly removed Rooney from the room, the latter fell, hit his head and died, police said.

Charged with murder, Kuchynsky later died in jail of natural causes.

Richard Kuppelweiser, former Mayview CEO, said he believes community hospitals are doing some of the state hospital's work. When Mayview was open, he said, local hospitals discharged their most complex cases there.

"It sort of moved the problem along," Mr. Kuppelweiser said.

'Satellite' state hospitals

Mr. Cvitkovic and officials of other hospitals see a need for a regional forensic unit to serve patients who are violent or sexual predators. Some also see a need for small state hospitals or an intermediate care facility to serve the severely and persistently mentally ill, as well as those who simply have lost control of a mental illness and need a place to get well.

"You can have a chronic illness become very acute, and that is a cycle for people with mental illness," said Mr. Bogdan, who advocates the creation of "satellite" state hospitals.

New state hospitals would fly in the face of the state's push for deinstitutionalization, but state Rep. Thomas Caltagirone, D-Berks County, said he wants to consider the idea. At his urging, the House in May directed the Joint State Government Commission to examine how the state provides mental-health services.

The review, which he said is the first in three decades, could take as long as a year. Ms. Vicari said the DPW is open to a review of treatment practices, but remains committed to an emphasis on community care.

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Joe Smydo: or 412-263-1548. First Published September 23, 2013 4:00 AM


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