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(This article was provided by Kaiser Health News.)

Elizabeth Cosgrove, left, helps Yolanda Solar, 73, who suffers from depression, organize her medications during a home visit on Nov. 3 in San Antonio. Cosgrove is a community outreach worker at a transitional care clinic run by the University of Texas Health Science Center at San Antonio. (Bahram Mark Sobhani for KHN)

Elizabeth Cosgrove, left, helps Yolanda Solar, 73, who suffers from depression, organize her medications during a home visit on Nov. 3 in San Antonio. Cosgrove is a community outreach worker at a transitional care clinic run by the University of Texas Health Science Center at San Antonio. (Bahram Mark Sobhani for KHN)

Yolanda Solar has battled a life-threatening disease for more than three decades. The disease nearly killed her last summer and Solar, a 73-year-old grandmother, was rushed to the hospital by ambulance.

When Solar was discharged one week later, she received bad news: She would have to wait until March to see a doctor.

Waiting seven months for treatment would be unthinkable if Solar had cancer or heart disease. But Solar suffers from severe depression, and waiting that long for help is typical — and potentially dangerous.

Although San Antonio has earned widespread praise for its success in keeping people with mental illness out of jail, patients here routinely wait months to see psychiatrists, who are in short supply across the country. The number of available psychiatrists who specialize in the care of the elderly or children is even smaller.

Without routine medical care, patients like Solar, who tried to kill herself in August with an overdose of pills, can quickly deteriorate. Many return to the emergency room. Some don’t survive.

But Solar was luckier than most.

Emergency room (ER) staff made an appointment for her at a transitional care clinic at the University of Texas Health Science Center at San Antonio, which annually treats up to 1,500 patients with serious mental illness until they can find regular care. The clinic helps the mentally ill avoid winding up in the ER, where round-the-clock activity and confusion is ill-suited to the needs of patients who are already agitated, suicidal or psychotic.

Communities like San Antonio are increasingly focused on reducing emergency room use by people with mental illness. In addition to being chaotic, emergency rooms are among the most expensive places in the health system to get urgent care.

Patients like Solar end up in the ER because they can’t find care in the community, and emergency rooms can’t legally turn anyone away. The mentally ill can be stranded in the ER for hours, days or even weeks with minimal treatment, because doctors deem them too disabled to discharge, but can’t find them an inpatient psychiatric bed, which would allow patients to get more intensive care.

More than half of emergency room physicians said their local mental health system has gotten worse in the past year, according to a survey of 1,716 members of the American College of Emergency Physicians, released in October. Seventy-five percent of ER doctors said on their last shift, they saw at least one psychiatric patient who needed to be hospitalized.

“The emergency department becomes the de facto dumping ground for all mental health patients,” said Gillian Schmitz, a San Antonio emergency physician.

The number of ER patients with a mental illness grew from 4.4 million in 2002 to 6.8 million in 2011, an increase of 55 percent, according to a 2016 study in Health Affairs. About 836,000 Americans a year go to the emergency room after harming themselves, according to the Centers for Disease Control and Prevention. Nearly 43,000 Americans committed suicide in 2014 — more than are killed annually in car accidents.

The American College of Emergency Physicians devoted much of its annual meeting in October to patients with psychiatric crises.

Everyone suffers when people with mental illness are stuck in limbo in the ER, Schmitz said. Other patients face longer waits for care and hospitals lose money. That’s because insurers pay emergency rooms only for their initial encounter with a patient, but not for time spent waiting for an inpatient bed.

“Every hour we are holding a psych patient,” Schmitz said, “is lost revenue that hospitals could be earning on other medical patients.”

Elizabeth Cosgrove, right, helped 73-year-old Yolanda Solar make a reminder to take her medication that Solar put on her dresser. Cosgrove is a community outreach worker at a transitional care clinic run by the University of Texas Health Science Center at San Antonio. (Bahram Mark Sobhani for KHN)

Elizabeth Cosgrove, right, helped 73-year-old Yolanda Solar make a reminder to take her medication that Solar put on her dresser. Cosgrove is a community outreach worker at a transitional care clinic run by the University of Texas Health Science Center at San Antonio. (Bahram Mark Sobhani for KHN)

Personalized care

Solar’s story also shows the progress that people with mental illness can make when they receive prompt and comprehensive care. She has not returned to the ER since beginning treatment in August.

Hospital staff scheduled her appointment at the transitional care clinic through a web-based computer system before she left the hospital. Like most patients, Solar was seen within a few days.

Solar now meets regularly with a psychiatrist, who manages her medications, and a counselor to discuss her fears.

A therapist visits her at home to help organize her medications, which include pills for high blood pressure and cholesterol. The visits are paid for through a Medicaid pilot program, which allows staff to provide extra services for up to five patients who are considered “high utilizers” of health care, or patients who are particularly costly to insurers because of repeat trips to the hospital or ER, said Megan Fredrick, the clinic’s program manager.

Patients with serious mental illness, which can cause cognitive changes similar to dementia, often need help with day-to-day tasks, said psychologist Dawn Velligan, project director at the transitional care clinic. Therapists help patients set alarms that remind them when to take their medicines. They work with patients on calendars and organizational skills, so that clients don’t miss appointments.

Through a type of therapy called cognitive adaption training, clinic staff teach basic skills, such as how to shop for groceries or take the bus to a medical appointment, Velligan said.

Only 2.5 percent of psychiatric patients seen at the transitional care clinic return to the ER within three months, compared to 10 percent of patients who aren’t seen at the clinic, Fredrick said.

Without the clinic’s help, Solar said, she would probably have considered suicide again.

“Sometimes, I get pretty, pretty, pretty depressed,” said Solar, who was raised by an alcoholic father. Her depression began, Solar said, during an unhappy marriage.

Yet for years, Solar suffered in silence. The first time she saw a psychiatrist was after her August suicide attempt.

Nationwide, more than half of people with mental illness go without treatment, according to Mental Health America, an advocacy group. The reasons are complex. Many people with mental illness don’t realize they’re sick, or that treatment can help. Some patients lack transportation or money to pay for care. About 17 percent of people with a mental illness in the U.S. are uninsured, according to Mental Health America.

“For many of our elderly Hispanic patients, this is the first time they’ve seen a therapist,” Cynthia Sierra, a clinic counselor. “You’re raised not to talk about your problems with strangers … You can carry years of burdens and trauma.

Unsolved problems

For all its success, the transitional care clinic can’t help everyone.

With an annual budget of $3.5 million — provided by a variety of grants and a fund for Medicaid demonstration projects — the clinic sees just a fraction of those who need help.

“We constantly have to beg for money,” Velligan said.

Although the transitional clinic accepts patients covered by Medicare, Medicaid or private insurance, it can’t accept most uninsured patients.

Psychiatrist Harsh Trivedi describes the program as a “Band-Aid” that fails to address the larger problem of inadequate care for people with mental illness.

“Unfortunately, creating these programs doesn’t actually solve the real access issues,” said Trivedi, chair of the American Psychiatric Association’s council on healthcare systems and financing.

Trivedi notes that the national shortage of psychiatrists means that even well-insured patients often have to wait for care. Although the overall number of physicians increased 14 percent from 2003 to 2013, the number of psychiatrists fell by 10 percent when adjusted for population growth, according to a July study in Health Affairs.

That shortage is projected to worsen over the next decade as large numbers of psychiatrists reach retirement age, said Trivedi, who is also the president and CEO of Sheppard Pratt Health System in Maryland.

Many psychiatrists have stopped taking insurance because health plans pay them too little to sustain a practice, Trivedi said.

To really help more patients, the country needs to rebuild the mental health system, investing both in outpatient care, more hospitals beds and supportive services, Schmitz said. Instead, states have been steadily slashing mental health budgets for years.

“As a society, we’re OK with the fact that someone with depression isn’t able to get care,” Trivedi said. “That double standard allows some of our most vulnerable people to end up in harm’s way.”

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Iowa has one of the highest quality, lowest cost health care systems in the United States. And at the heart of that system are 118 community hospitals that stand ready, day and night, to serve everyone, regardless of their ability to pay. A significant reason for health care excellence in Iowa has been state oversight of institutional health care services through the Certificate of Need law.

Iowa’s Certificate of Need regulations were first enacted in 1977 for the express purpose of providing for the orderly and economical development of health care services, thereby avoiding unnecessary duplication of services, controlling the growth of overall health care costs and ensuring the stability of community hospitals. Since that time, these regulations have been re-examined multiple times and each time the same conclusion was reached: Iowa needs Certificate of Need.

As the name implies, Certificate of Need ensures that new medical services are truly needed at the community level. This is important because new facilities (including nursing homes, ambulatory surgical centers and hospitals, among others) must have sufficient patient volumes to support proficiency among medical staff and ensure high-quality care. The same applies to existing facilities, yet without Certificate of Need, new, for-profit facilities would spring up all over the state and deplete patient volumes across the board.

Not only would this compromise the quality of care for everyone, but these new facilities would target lucrative lines of medical service while not providing emergency care, charity care and other unprofitable services that are at the core of the community hospital mission. If Iowa’s community hospitals are left with only unprofitable services and only care for complicated patients who are on Medicaid or uninsured, their ability to survive and continue providing high-quality, community-focused care to everyone will be jeopardized.

In fact, repeal of the law in other states has led to hospitals closing. Furthermore, nearly all of these states have instituted a different review process that is highly politicized.

One of Iowa’s greatest strengths is its health care system. Not only do Iowa’s health care providers deliver excellent, accessible and efficient care, but health care employs more than 200,000 people, injecting some $11 billion into the state’s economy. More than 71,000 of these workers are employed by hospitals, which alone have an economic impact of $4.3 billion.

Certificate of Need, which exists in 36 states, not only ensures the stability of these major employers and economic engines, but it also supports the collaborative spirit that fosters communication and cooperation among Iowa health care providers, which, again, leads to better health care for everyone.

Today, with the uncertainties surrounding the future of the Affordable Care Act (Obamacare), Iowa’s Medicaid program and even Medicare, the constancy of Certificate of Need is more important than ever. During this time of significant change in the health care industry, the stability provided by this law allows hospitals to more confidently plan and respond to the needs of the communities they serve.

In all parts of the state, Iowans depend on their community hospitals being there all day, every day. That level of access and preparedness is jeopardized by those who would significantly change or repeal Certificate of Need.

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(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.

emt2Increasingly, 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.”

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Although Iowa has made attempts to improve its behavioral health care delivery system, the system remains fragmented and is in need of more – more financial resources, more health care providers, more access points for patients needing services and more community resources to keep behavioral health patients healthy. Hospitals see this need every day when patients in need of behavioral health services arrive in emergency rooms (ERs) as a last resort, and only hope for treatment. However, most hospital ERs are already overloaded and are not equipped to provide sufficient care for mental health patients.

What’s often needed are crisis-intervention and short-term, sub-acute care as well as post-acute care that allows patients to transition back into their communities. These services are currently difficult to find in Iowa, but where they do exist, they help ensure patients receive the right care close to home.

One place where such care is available is Oak Place in Centerville, where a coalition from Mercy Medical Center-Centerville, Appanoose County, law enforcement, District Court and others have worked together to implement this effective solution. As a “stabilization home,” Oak Place not only provides therapy, but also helps identify and meet immediate needs for local residents in crisis, including shelter, food and clothing. Most importantly, working with on-call licensed therapists, the local ER and jail can request a mental health screening at any time, ensuring that patients have their needs identified in a timely fashion and then met in an appropriate care setting.

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Although Iowa has made attempts to improve its behavioral health care delivery system, the system remains fragmented and is in need of more – more financial resources, more health care providers, more access points for patients needing services and more community resources to keep behavioral health patients healthy and close to home. Iowa’s hospitals are leading the call for investing in and improving the system. Watch this video or visit this web page to learn more.

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