Showing posts with label AMRTC. Show all posts
Showing posts with label AMRTC. Show all posts

Saturday, May 14, 2016

News Flash From Channel 5: "There is a shortage of psychiatrists"





This was an actual headline from a local news channel.  Of course the first question is where have they been for the last 30 years?  That was about the last time Anoka Metro Regional Treatment Center (AMRTC) was adequately staffed by psychiatrists.  In fact, at that point some of the psychiatrists working there considered it to be a high point in the education of medical students from the University of Minnesota.  One of them told me that their clinical rotation was the highest rated of any in the department.  The gist of this story is that the shortage of psychiatrists has led to inconsistent staffing for patients who need consistency.  The reporter emphasis was on Minnesota Department of Human Services hiring three psychiatrists with disciplinary actions on record with the Board of Medical Practice.  They also make the point that many of their psychiatrists are flown in for a few weeks at a time to see patients and this disrupts continuity of care.  The mother of a patient and a State Ombudsman comment about the importance of continuity of care.  If you watch the entire clip, the end is rather anticlimactic as the reporter points out that Minnesota is really no different than other states.  They are all suffering from the shortage of psychiatrists.

All in all a very dramatic presentation of a problem that nobody wants to solve.  After all, I just pointed out that in the late 1980s and early 1990s staffing at this same hospital was excellent.  The psychiatric staff there was first rate and one of the best hospital staffs that could be found anywhere.  So what happened?   In a word that I have used frequently on this blog mismanagement.  At some point professional managers decided to ignore the once popular theories of Peter Drucker and manage professional workers like production workers.  They saw psychiatry as a production job and eliminated the systems aspects critical for a team approach to psychiatric treatment.  That team approach is also critical to the practice environment and the practice environment and patient care also suffers when governments and insurance companies start telling physicians what to do and what to prescribe.  The outcome is as predictable as the current failed state hospital system.

None of those basics are in this sensational piece from Channel 5 News.  The only narrative I can detect in this story is that there are long distance psychiatrists and problematic psychiatrists practicing problematic psychiatry at the state hospital - at least until the main reporter starts with a focus on the shortage of psychiatrists.  Psychiatrists in this story function only as scapegoats.  That is easy to do when you limit the practice and hire people who are willing to work in a compromised treatment environment.  It is also easy to do when you eliminate psychiatrists and experienced psychiatric nursing staff from the management and planning aspects of the system.   Just last week I pointed out that there were no psychiatrists on a Governor's Task Force on Mental Health.  There are no psychiatric experts discussing hospital care or what it will take to repair the system in the news piece.  It is as if we are in a parallel universe, pretending that politicians and bureaucrats can do the job of psychiatrists without any training.  They can turn around and ration access to psychiatrists and then blame psychiatrists for all of the problems they have created.    Luckily,  I have been writing about this curious set of circumstances here for a few years.  You can follow my commentary in the links below and see how it compares to the skewed news version.

The additional question any reader should ask is why psychiatrists are never consulted and why attorneys and bureaucrats with no psychiatric training are in charge of these facilities?  This the cultural trend that started 30 years ago.  Throw out the doctors and run the healthcare system with politicians and bureaucrats that tell the doctors what to do.  Make is seem like doctors in state hospitals can operate in a vacuum rather than on teams and have the bureaucrats tell them how to manage clinical problems.  For a good portion of that 30 year period the word on the street was that the State of Minnesota was shutting down state hospitals and they were going to shut down AMRTC.  Those rumors do not inspire the confidence or commitment from medical or nursing professionals that you need to build a first rate state hospital system.  Who wants to go through credentialing and all that professional applications involve to apply to a hospital that is rumored to be closing soon?

The problem in Minnesota is not about trusting psychiatrists, no matter how bad a media article attempts to portray them.  This article is about trusting the politicians and bureaucrats that run this system.  In 30 years those politicians and bureaucrats have done nothing to merit anyone's trust in managing the public system of mental health care.  The failed state mental health system in Minnesota is an excellent example of what happens when you leave the management of a profession up to amateurs.


George Dawson, MD, DFAPA



Previous posts on the management deficiencies in the Minnesota state mental health system (click on the last word in each line for the post):


Executive Order: No Psychiatrists On Governor's Task Force On Mental Health [ 5/4/2016 ]

Minnesota's Mental Health Crisis - The Logical Conclusion of 30 years of Rationing [11/2/2015 ]

Minnesota State Hospitals Need To Be Managed To Minimize Aggression [1/6/2016 ]

Minnesota Psychiatrist Workforce Shortage [12/2/2015 ]

The CMS Investigation Of Anoka Metro Regional Treatment Center [1/19/2016 ]

Minnesota Finally Rejects Managed Care [5/29/2015]

More On Violence And Aggression In Minnesota Hospitals [12/11/2014 ]

Minnesota Continues A Flawed Approach To Serious Mental Illness And Aggression [12/9/2014 ]

The Shadow State Hospital System [ 11/6/2014 ]



Wednesday, January 6, 2016

Minnesota State Hospitals Need To Be Managed To Minimize Aggression


























When is that going to happen?  How much time will it take?

According to new Minneapolis StarTribune article by Chris Serres the situation at the state's second largest state mental hospital has worsened to the point that it has caught the attention of regulators from the Centers for Medicare and Medicaid Services (CMS).  CMS put the state on notice that it at risk for losing $3.5 million in federal funding if they don't correct patient safety issues at the hospital by March 5.  The hospital is described as having experienced a "surge" in violence and aggression with associated injuries since the state Legislature passed a 48 hour rule mandating that jail inmates identified in as having mental health problems be directly admitted to Anoka Regional Metro Regional Treatment Center.  The jail inmates were given priority status over any civilly committed persons in community hospitals.  The article points out that there have been 38 aggression-related injuries involving 24 patients in 2013 and 48 aggression-related injuries involving 28 patients in 2014.  A direct assault on a staff person is described in the article.

I have a few suggestions for legislators, bureaucrats, and citizens of the State of Minnesota on how this can be resolved as soon as possible.  Let me preface this by saying that I have no special knowledge about what is happening at AMRTC apart from what is in the Seres article.  I am one of a handful of psychiatrists in the state who have worked in these settings and am qualified to comment on these issues.  I have a formal request in to the Department of Human Services to review a copy of the CMS report because I cannot find it on the Internet, the DHS web site, the CMS web site, or the office of the Inspector General.  My suggestions follow:

1.  Rescind the 48 hour rule to send unscreened jail inmates to AMRTC immediately:

Any psychiatrist could have provided consultation at the time on the reasons why this will not work, but the biggest reason is that psychiatric symptoms or even a psychiatric diagnosis does not necessarily mean that a psychiatric hospital is the best place for the patient.  Patients admitted to inpatient units are screened for psychiatric disorders and not on the basis of alleged criminal behavior.  In terms of logistics within the state hospital system patients who are dangerously aggressive have generally been committed as mentally ill and dangerous and generally sent to the Security Hospital at St. Peter. It is fairly common to encounter sociopathic and psychopathic patients in community psychiatric hospital.  It soon becomes obvious that apart from the personality disorder and the associated aggressive and inappropriate behaviors that there are no treatable problems.  This patients often become aggressive toward staff or exploit other patients and are immediately discharged from inpatient settings.  Inpatient psychiatric settings are not the correct place to address antisocial persons or in many cases antisocial persons even with a psychiatric diagnosis because of their danger to staff and other patients.

There is the associated issue of there being a strong incentive to send patients who may be difficult to work with but who are not psychiatrically ill to the hospital just because the rule exists.  Transfers like that always occur to psychiatric units if someone has carte blanche for admitting people and psychiatrists don't screen them.  Aggression can be minimized only when the entire unit is managed with a safety focus and that includes screening anyone with aggression who is admitted.

2.  Reanalyze the culture at AMRTC with an emphasis on staff safety:

It is really impossible to run a psychiatric hospital if the staff responsible for the care of the patients are threatened and/or burned out.  The article lead me to believe that both things are happening and compounded by the fact that hospital staff is being mandated to work extra hours.  In the initial stages that may require the presence of additional security staff.  I have seen similar situations where the level of antisocial and aggressive behavior on an inpatient unit became overwhelming resulting in a riot situation that required police intervention.  Some attempts at splitting up large state hospitals to smaller local facilities in the state have resulted in similar incidents.

A critical element of the culture that has come to light in recent years is the fact that there appears  to be a top down initiative in the management of state facilities.  Aggressive behavior has been an ongoing problem at state facilities.  Psychiatric input into that problem is not clear.  It is clear that in at least some cases, programs were implemented by management staff who have no expertise in managing aggression and violence in inpatient settings.

Like most psychiatric problems aggression is a treatable problem, but it has to be addressed directly.  It is best address in an environment that identifies it as a treatable problem immediately rather than an untreatable characteristic or one that has a root cause that must be addressed first.  There is not better way to treat aggression than identifying it as a primary problem that is incompatible with a therapeutic environment.

3.  Take a serious look at how inpatient psychiatric facilities are supposed to run:

State governments and managed care systems have both had deleterious effects on psychiatric care on inpatient units.  These management systems have a lot in common in determining what happens on the inpatient side.  The absolute worst case scenario is containment only.  People are basically held usually based on the premise that they are dangerous in some way.  Dangerous in this context generally means at risk for aggressive or suicidal behavior.  They are discharged when that dangerousness passes either by the administration of medication, the person resolving a crisis in their life, or until they convince staff that they are no longer dangerous.  This approach to inpatient care seriously dumbs down psychiatry, treats patients like widgets on an assembly line rather than individuals, and creates the illusion that anyone can do inpatient psychiatry.  Dangerousness after all is not a psychiatric diagnosis.  It also creates the illusion that an inpatient psychiatric unit is tantamount to incarceration or jail.  It leads to a correctional atmosphere in what should be a therapeutic hospital environment.  In a correctional atmosphere, the staff seem to be policing the patients rather than working with them on common goals.  This attitude has also led at least one state official to suggest that psychiatrists in this environment are optional.  A local mental health advocate has said the same thing.  If that is true - why is it that the state of aggression in this hospital has gotten to the point that the union representative in the article is suggesting that the institution is being run by the patients?


4.  Rexamine the funding and rationing of psychiatric care in Minnesota:

The article mentions a backlog of patients at AMRTC due to the fact that many of them cannot be discharged.  This has been a problem in Minnesota for as long as I can remember.  Patients are committed in acute care hospitals and end up waiting there too long for transfer to AMRTC.  Once they get to AMRTC they meet criteria for discharge and there is nowhere for them to go, largely because they still have chronic psychiatric symptoms that are socially unacceptable or that preclude their safety in the community.  Anyone who is covered by standard health insurance is no longer covered if they are committed to a state hospital.  People can end up undergoing civil commitment because their insurance companies do not provide the level of care that they require in the community.  The entire system of fragmented and rationed care can be viewed as a way for the government and managed care companies to minimize their funding of necessary care, especially in patients with complex problems.  A basic option here is to expand care based on treatment parameters rather than rationing criteria.  Develop treatment based and quality goals rather than rationing goals that provide minimal and frequently inadequate care.  One of the basic principles of community psychiatry is that the funding needs to follow the patient.  If patients are committed and transferred to state hospitals and they are on private insurance plans - those plans need to have continued financial responsibility for those patients.  If a patient with private insurance needs treatment in jail, those services need to be covered by private insurance rather than being shifted to law enforcement.  The entire system of rationing and cost shifting is also a strong incentive to transfer any mentally ill inmate to AMRTC because law enforcement is covering the cost of medical and psychiatric care.  

5.  Facilities for mentally ill inmates that recognizes their vulnerability:

One of the concerns that I have always had for any inmate with a mental illness, is that they are generally much more vulnerable to any form of manipulation or intimidation by career criminals and sociopaths.  The second concern is that many patients with mental illnesses end up in jail because they are symptomatic and/or confused and end up trespassing or in dangerous situations.  They are often not able to follow instructions by the police.  Some Minnesota counties have mechanisms to safeguard this population.  One of them is having them screened in jail for competency to proceed to trial by qualified psychiatrists and psychologists.  The resolution in those cases is that the patient is transferred to an inpatient psychiatric unit for stabilization and the pending legal charges are usually dropped.  They can frequently be discharged from the acute care hospital without transfer to a state hospital.  In cases where this does not occur, every effort should be made to segregate the vulnerable inmates who are mentally ill from the general jail or prison population.  The ideal situation would allow for more programming to prevent some of the common correctional problems like isolation that lead to increasing symptoms.    

These are a few suggestions to resolve the current problems with aggression noted to exist at at AMRTC.  Over the years that I have been following this story, there is also the question of what is really going on in these facilities?  Why are these problems so difficult to resolve when acute care hospitals have fewer problems and are dealing with more acutely agitated and frequently intoxicated individuals.  Why does the bureaucracy think they can resolve these problems without using psychiatric expertise or at least methods that have been proven to work in psychiatric institutions?  And what about the alternate and seemingly more permissive methods of dealing with aggression?  Can anyone come out with a comment on whether or not they have succeeded or failed?  There is a lack of transparency when it comes to seeking the answers to these questions.

These are all important questions that need to be answered.  I hope to receive the CMS report and make further comments on this situation.  There is a lack of transparency about what the state is doing to resolve this situation.  When the state assumes the care of mentally ill individuals - people who by definition are vulnerable adults, transparency is important to assure their adequate care and reassure the families of all of the patients admitted to this hospital.


George Dawson, MD, DFAPA




References:


1:  Chris Serres.  State psychiatric hospital in Anoka threatened with loss of federal funding.  Minneapolis StarTribune January 4, 2016.


Attribution:

The jail photograph at the top of this blog is by Andrew Bardwell from Cleveland, Ohio, USA (Jail Cell) [CC BY-SA 2.0 (http://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons.  The URL is: https://commons.wikimedia.org/wiki/File%3ACela.jpg