(This article was provided by Kaiser Health News.)
For Kelly Kjelstrom, plugging the gaps in mental health care can mean something as simple as a late-night taco and a friendly chat.
Kjelstrom, 45, is a community paramedic in Modesto, California. Part of his job is to help psychiatric patients in need of care avoid winding up in the emergency room, where they can get “boarded” for days, until they are released or a bed frees up at an inpatient facility.
Here’s how the concept of community paramedics works. When the local 911 system comes upon a patient with a potential mental health crisis, these specially trained paramedics are dispatched to the scene. They’ve learned to identify problems, intervene and de-escalate the situation.
After a physical assessment, paramedics like Kjelstrom talk to the patient — to figure out what, precisely, the issue is, asking also about issues like a patient’s mental health history, drug use and insurance status. They use that information, along with details about resources available, to figure out the next steps for the patient — maybe it is a hospital or a psych facility, or maybe it is outpatient care.
Increasingly, these paramedics also become involved in follow-up. Kjelstrom estimates that, on visits, he spends twice as long with patients as he used to. He builds relationships with them. While out on duty, if he runs across a familiar face, he stops and checks in. Like over a night-time snack.
“One of the patients we see on a regular basis,” Kjelstrom said. “I buy him a taco, no big deal, and I remind him to take his meds.”
That simple interaction, he said, can keep someone out of the ER, and on the path to better health.
The Modesto pilot program launched a year ago. Similar projects are also underway in North Carolina, Minnesota, Texas, Colorado and Georgia. Other states, such as Washington and Nevada, have shown interest.
“Emergency departments are bursting at the seams,” said Kevin Mackey, medical director of the Mountain Valley EMS agency, who launched the Modesto initiative, which has now been operating for a year. “This is at least a partial answer to giving people care in the right place at the right time.”
Those efforts come as the issue of mental illness, which affects about 1 in 4 adults, continues to be a national concern and cases like October’s police shooting of a woman with schizophrenia in New York spark conversation about ways to better reach these patients.
“If we could coordinate care — if we have the right medications and the right coordinating approach to these patients, we can avoid shooting people,” Mackey added.
Jurisdictions are beginning to see the benefits.
In Wake County, North Carolina, for instance, a third of mental health-related 911 calls are now sent to specialized psychiatric facilities, said Michael Bachman, deputy director at the county’s Office of Medical Affairs. That’s about 350 patients a year who would otherwise have gone to the emergency department.
But patients can only be connected with the treatment they need if there are doctors or treatment sites available. Often, they aren’t.
In addition, no one has been able to track whether these patients stay healthier, Bachman acknowledged.
And that’s in part because of another issue. Paramedics can only redirect patients from the ER if there’s somewhere else to take them and if they’ll get proper follow-up care after. Far too often, experts said, that isn’t the case.
“This works,” Bachman said. “But the thing that has to improve is there has to be more access to places for patients to go.”
In Modesto, Kjelstrom will see patients who would most benefit from a short stay in a dedicated mental health facility. But he’ll often run up against the issue that the local centers just don’t have enough beds to take patients in need. That limits how effective he can really be, he said.
Mackey said he estimates 30 percent of the time that patients needed to go to an inpatient facility, there wasn’t a bed available. It’s a similar story elsewhere. For Atlanta-based Grady Health System, which launched a paramedic program in 2012, finding available bed-space remains “a pretty big challenge,” said Michael Colman, the system’s vice president of EMS operations.
And then there’s follow up.
“If we’re talking about using community paramedics — or social workers, or some other community organization — to connect people with behavioral health care services, [these kinds of barriers] are an issue,” said Kate Blackman, senior policy specialist for the health program at the National Council of State Legislatures.
Even so, experts said, it’s a promising first step.
“We’re moving in the right direction with programs like these,” said Karen Shore, a principal at the California-based consulting firm Transform Health. “It isn’t solving all of our health system problems. But that’s not a fair expectation.”
Iowa’s already-struggling mental health care system has taken another hit , as Ellsworth Municipal Hospital (EMH) in Iowa Falls announced that, within the next two months, it would be closing its inpatient behavioral health service and its chemical dependency program.
This was not an easy decision for EMH leaders to make. Only a handful of mental health programs like these exist in Iowa and the services at EMH are heavily used by patients from all over the state. In fact, only 15 percent of the hospital’s inpatient behavioral health patients come from Hardin County. This is no surprise; after all, 83 of Iowa’s 99 counties are considered mental health professional shortage areas. With only about seven practicing psychiatrists for every 100,000 residents, Iowa ranks 47th in the nation for access to mental health care.
In Iowa Falls, EMH has done all it could to keep its inpatient program functioning. The hospital streamlined the program, reduced staff and discontinued its transportation program. But because of lagging reimbursement, particularly from Medicare and Medicaid, the program has been a drain on overall hospital finances. This is a problem for all Iowa hospitals offering behavioral health services, but the impact is much greater for small facilities like EMH, which do not have the patient volume to make up for the losses. This is why only a handful of these small hospitals offer any kind of behavioral health program (inpatient or outpatient).
The good news for people in and around centrally located Hardin County is that inpatient behavioral health services in Des Moines and Waterloo are relatively close by. For much of the rest of Iowa, particularly in the western half of the state, the distances are much greater.
What needs to be done? IHA is advocating for programs that would attract more psychiatrists to the state, such as student loan repayment programs. Expanding telemedicine services through high-speed Internet would allow more patients to utilitize online counseling rather than having to travel to urban areas where behavioral health programs and practitioners are concentrated. IHA has been steadfast in pushing to keep the state’s mental health institutes in Cherokee, Clarinda, Independence and Mount Pleasant open – Iowa needs more access to mental health services, not less.
IHA also continuously advocates for increasing Medicare and Medicaid payments to hospitals and doctors. Hospitals lose millions of dollars each year because these programs do not cover the full cost of care.