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Iowa’s Certificate of Need (CON) 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.

Now the Iowa Legislature is considering a bill that, if enacted, would repeal significant portions of the CON program, putting community-based health care at risk. Here are some of the reasons why Iowa hospitals are supporting CON:

CON ensures access to health care services

  • CON repeal will reduce access by destabilizing local health care systems.
  • Without CON, services that keep hospitals financially healthy will be stripped away by for-profit, out-of-state, investor-owned organizations that selectively perform services simply because those services are likely to create the most income.
  • These niche providers would leave the financial burden on hospitals to provide 24/7/365 emergency care, to provide care for patients with complicated conditions and patients with Medicaid or no insurance.

 CON supports rural communities

  • States without CON have seen hospitals close, especially in rural areas.
  • Rural Iowa is uniquely susceptible to losing essential health care services. CON criteria and safeguards ensure health care systems are financially stable and that health care options exist throughout all of Iowa.
  • In many counties, rural hospitals are among the largest employers, bolstering Iowa’s rural economy, attracting and retaining young professionals and families and bringing high-quality jobs where they are most needed.

CON promotes quality health care services

  • CON criteria ensure new facilities operate with patient volumes that are sufficient to provide high quality services.
  • CON criteria ensure excess capacity does not lower volumes in a manner that compromises patient safety.
  • CON criteria result in consideration of the quality services available in the community.

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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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Dwight Dial

As he sits in the kitchen of his Lake City farm home, Dwight Dial is surrounded by items that remind him of his loved ones: a barometer his mother passed down to him from Swedish ancestors, photos on the fridge of children and grandchildren, embroidered wall hangings completed by his beloved wife, Jane. It’s a comfortable room in a sprawling farmhouse, but at the moment, it’s quiet. The only sound in the house is Dwight’s voice as he remembers three people he lost within three years.

His father, Gerald, was a tail gunner in a B-17 bomber during World War II in the European theater. He flew 36 missions and was featured in a book written about the “Flying Fortress.” Gerald rarely discussed his experiences with his family, who only came to realize the dangers he had faced when they read the book. “We told each other we’re lucky to be here!” recalls Dwight.

After the war, Gerald returned to the farm and married Alice Ann. Together, they raised seven children and tended the land. When he was 85, a lifetime of smoking resulted in a diagnosis of chronic obstructive pulmonary disease (COPD) and emphysema. In 2009, he began to utilize Community Hospice at Stewart Memorial Community Hospital (SMCH) in Lake City. Hospice is a special kind of care that brings terminally ill patients and their families comfort, support and compassion in a manner that respects and cherishes the dignity and uniqueness of each individual. When cure is no longer possible, hospice can provide highly skilled care to patients and their families in the familiar surroundings of their own home or residence, including nursing homes.

Dwight recalls, “The nurses would come to the house to take care of him. My parents were very private, but I think my folks shared more of their personal lives with them than they did with their children.” He was impressed with the level of care his father received at the hands of the hospice team. “At one point, my father decided to stop going to see his doctor for checkups. The nurses communicated with his physician who then made a housecall. Together they decided to let mom continue to take care of Dad in their home with the help of the hospice nurses. When he passed on December 6, 2013, his last words to mom were ‘I’m glad you kept me at home.’”

In May 2011, Dwight and Jane were visiting their son in Alabama who was preparing for his third tour of duty in Iraq. They were playing with their grandson when Jane suddenly said to Dwight, “Something’s not right inside.” When the couple returned home Jane made an appointment with her primary care provider Nancy Flink, certified physician assistant. Tests revealed that Jane had ovarian cancer. Dr. Marc Miller performed surgery in June and Jane, a long-time Nutrition Services Director at SMCH, began chemotherapy at the hospital that felt like home.

On August 28, 2013 the couple celebrated their anniversary with dinner, margaritas and laughter. Dwight recalls that it was their last meal together. A few days later, Jane was taken to Des Moines to receive care from her oncologist where she stayed until October. When she was able to return to her home, she opted to do the next round of chemotherapy at the Lake City hospital, entering the hospice program at the same time. “Everyone at the hospital worked to make sure Jane was comfortable. The maintenance crew brought a hospital bed, then went and got a new mattress for it, while Bethany Morrow made sure Jane had new sheets and anything else she needed. Friends came to sing Christmas carols for us and later hung Valentine’s cards all over the walls,” says Dwight.

The hospice team helped with bathing Jane and medications. They trained Dwight on how to care for her ileostomy and how to give her nutrients through a port after she was unable to digest food. Dwight pauses for a long moment, “Jane passed away on December 26, 2013, 20 days after her father-in-law. She didn’t want to go before Dad and she didn’t want to go on Christmas day. That morning she said to me, ‘I made it.’” Softly, Dwight continues, “I told her it was okay for her to go, and she went.”

A few months passed and Dwight continued to farm. In June 2014, his mother, Alice Ann was diagnosed with breast cancer. Dr. Miller performed a mastectomy, but the disease had spread into her lymph nodes. “My mother was very strong. She went home and convalesced for a few weeks on her own and then began a series of 29 radiation treatments. After she completed 20, I took her to California to see her sister. When we returned she completed the last nine.”

Before Thanksgiving that year, Alice Ann acquired an infection and was hospitalized for 100 days. Dwight decided to take her home to his house where he could care for her. “The wound nurse showed me how to clean and pack her wound. The hospice nurses were also there to help care for Mom.” Throughout 2015, Alice Ann was in and out of the hospital but on December 5 she returned to the hospital for the final time. She told Dwight, “As soon as I’m well enough, I’m going to go to Shady Oaks.”

She reached that goal on December 9. “The hospice team was involved in mom’s care at the hospital and the nursing home,” says Dwight. “The communication, care and support flow so well from the SMCH hospice team. They bent over backwards to make the process as easy as possible for the family.” Alice Ann passed away on December 31, 2015.

Dwight is grateful for the care shown to Gerald, Alice Ann and Jane, “Hospice gave my loved ones the ability to live out their last days in dignity and love, surrounded by people who truly cared. They became our family during those very critical days. The sincerity this staff has is unquestionable. For the compassion they have for those that are leaving us and for the caregivers, I cannot thank them enough.”

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When mental health issues become visible, it often happens explosively and tragically. The shootings at Newtown and Virginia Tech, along with countless other deadly crimes, were carried out by mentally unstable individuals. About a year ago, an Iowa veteran dealing with post-traumatic stress disorder was angered by two teens who were horsing around at an Ankeny McDonald’s. He shot and paralyzed one of them.

This is when, like a volcano erupting, mental health explodes across the headlines, only to eventually be replaced by some other disaster or scandal. But, as health care providers well know, the problem not only doesn’t go away, it’s getting worse. In fact, mental health is arguably Iowa’s top public health issue.

Unlike volcanoes, poor mental health and the dangers that can accompany it can be controlled. Where we are failing as both a nation and a state is in providing the right care in the right place at the right time.

Health care providers know this means many of the mentally ill end up in emergency rooms, but perhaps the most tragic evidence of failure are the number of mentally ill inmates in American jails. The National Alliance on Mental Illness estimates that nearly 15 percent of men and 30 percent of women booked into jails have a serious mental health condition. That’s about two million Americans each year.

Here in Iowa, 123,000 people live with serious mental health issues and 80,000 Iowa youths cope with severe emotional disorders. Yet Iowa has fewer psychiatric beds and mental health professionals than nearly every state in the nation.

The idea behind the “deinstitutionalization” of the 1950s and ’60s, and more recently the closing of two Iowa mental health institutes, is that the mentally ill could be helped more humanely while living and being treated in community settings. But the community-based infrastructure was never really put in place or properly supported, so a huge number of those released never got the local help they needed.

Now the price is literally being paid, as Iowans in need of mental health services are churning through emergency rooms and sometimes in jails, places that are costly not only terms of real dollars, but in their inability to properly address an individual’s long-term mental health. Good intentions in the form of deinstitutionalization are not enough, but there are solutions.

This is why during the upcoming legislative session, Iowa hospitals will be advocating for increased behavioral health care access across the continuum to help relieve the systemic bottleneck that has patients languishing in hospital beds or in jails.

Iowa needs a full care continuum in behavioral health that includes sub-acute services, crisis intervention, crisis homes, nursing facility care and community-based services. With that infrastructure in place, more hospital inpatient psychiatric beds will become available for patients who truly need them, while patients needing less intensive care will receive it close to home.

Properly investing in these more efficient and effective resources now will put our state on a path to reduce behavioral health care costs in the long run. Otherwise, reliance on stop-gap measures will continue to extract a high price from both Iowans and Iowa communities.

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In this season of giving, surgical services employees at Mercy Medical Center-Clinton have found a creative solution to give the perfect gift to those in need, while at the same time finding a use for material that would otherwise be thrown away.

“It’s just called ‘blue wrap,'” said Leigh Anne Piper, Mercy’s director of perioperative and cardiac services. “We get it in sheets and use it after our surgical supplies are cleaned and sterilized. The wrap is only used to cover the sterilized supplies until it is time to use them in the operating room.”

The waterproof, plastic mesh material would normally be thrown away after use, according to Piper. “We’ve always looked for something that we could do with it,” Piper said. “It’s such a sturdy fabric that throwing it away seemed wasteful.”

That’s when she presented the surgical services team with an idea and from there, it grew.

“I found online that some people made things with the blue wrap and that’s when I mentioned it to an employee in our department who took the wrap home and tried sewing the material to see how easy it would go together,” said Piper. After that proved successful, the idea for blessing bags took hold.

“We thought that if we could sew these together in a bag, we could fill them with items that could help some of our patients who are homeless or in need of basic supplies,” said Piper.

Once it was determined that the bags could be sewn, Piper and her team arranged a sewing night at Mercy. Employees were invited to bring sewing machines for a work session to put the bags together; 24 employees participated in the session.

Donations for items to place in the bag also generously poured in from departments across Mercy and an assembly line was set up in early December where employees could volunteer over lunch to fill bags. Each blessing bag contains a bottle of water, a blanket, hat, gloves, socks, toiletries, flashlight, food and a reference list to find help if needed. More than 108 bags were created and filled and are now ready to be given to patients in need.

“This project really demonstrates how we serve our faith-based Mission at Mercy,” said Amy Berentes, vice president of patient care, adding “not only do we provide care to those who come to us, but this project demonstrates how we live our faith and extend our care and compassion to those in need. The added benefit is that we are being good stewards of our resources, finding a meaningful use for material that would have otherwise gone to the landfill. I am proud of everyone who participated in any way in this project.”

Piper admits that it exceeded her expectations on how well the idea for the project took off and how inspired employees were to help. “As an organization, we live our mission every day in what we do, but it was absolutely heartwarming to see how everyone wanted to help. I am so proud to work at Mercy.”

The bags will be provided to any patient that any employee feels may need one. Piper credits her surgical services department and the entire Mercy team for the assistance in this project.  “I have had many colleagues tell me that they are excited to be a part of the project and really feel that these bags may make a difference in someone’s life.”

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