MPS Meeting on Emergency Department Congestion

From the Flyer for this Meeting - Not an indication that MPS has anything to do with the opinions that follow. 

I attended the Minnesota Psychiatric Society 2019 Fall Program last weekend. The theme was addressing Minnesota’s Mental Health Access Traffic Jam: Coming Together to Build a Better Roadmap. That traffic jam has been there for the duration of my career in Minnesota and that is approaching 30 years. 

When I looked at the agenda and the speakers my first association was “stakeholders”. That jargon has found its way into the administration of medical and psychiatric systems over the past 20 years. It is basically a codeword to suggest that administrators, politicians, and everybody in between somehow has a “stake” in medical care and the relationship of physician has with the patient and their family is peripheral to all of these outsiders.  Nothing could be farther from reality – but that is the attitude we have to deal with from politicians and administrators.

The keynote speaker was the director of Psychiatric Emergency Services at the Denver Health Medical Center – Scott Simpson, MD. He was not able to make and his presentation was given by a colleague - Kristie M Ladegard, MD. Denver Health is a 525 bed Level I Trauma center. Psychiatric Emergency Services has a 17-bed psychiatric unit and a 60-bed detox unit.  The Emergency department also has mobile crisis services and consultation services.  For the last data they had in 2013 a little over half of their emergency visits were for “depression, anxiety, or stress reactions”. About 40% were for substance use disorders. An additional 20% were for psychosis or bipolar disorder. As expected, suicidal ideation led to a more complicated disposition plan. The incidence of delirium in elderly patients remaining in the emergency department and the high mortality rate of missed delirium was discussed. Factors leading to boarding in the emergency department were discussed. An interesting approach to substance use treatment was the “No Wrong Door” approach. Using approach intake for substance use treatment occurred right in the emergency department or at other points of contact within the medical system.  Medication Assisted Treatment for opioid use disorder was also started in the ED, with buprenorphine inductions. That resulted in a greater number of inductions and greater percentage of people retained in treatment.

Emergency services lecture also talked about four goals of implementation including access, quality, cost, and provider resiliency. The most interesting method discussed knew the end of the lecture was Dr. Simpson’s paper on single session crisis intervention therapy (1). The specific techniques are given in the open access paper in reference number one, and they should be familiar to people who are involved in crisis intervention especially with people who are suicidal in those situations. It was part of the overall message that I don’t think is emphasized enough. That message is-interventions need to be incorporated into the clinical assessment and not compartmentalized into the few minutes at the end. Experienced clinicians should be able to forgo entire sections of a standard template if an intervention is necessary and they can use the time to provide it.

There was a complementary panel in the afternoon that consisted of two psychiatrists and two emergency medicine physicians in a dialogue about what each discipline wanted to tell the other. Early in my career it was often a source of conflict. There always questions about “inappropriate admissions” psychiatry. Those questions faded away without any psychiatric presence in the emergency department. People were admitted to my service irrespective of their associated medical complexity. It was often my job to determine whether or not they needed to be transferred to a medical or surgical service. With this panel there was not a lot of controversy. Much of the concern had to do with nursing home and group home patients being sent to the ED with no hope that they could be placed anywhere quickly. The ED physicians had a very valid argument that it is no environment for boarding people until placements are available. The spaces are confining and there is very little to do. Communication about these patients and what the outpatient staff’s expectations are is critical. One of the psychiatric panelists pointed out during the session that all of the presentations indicated that additional beds within the system were necessary - but the state and managed care representatives were denying that basic fact.  This was later denied by a state representative who tried to say that there are a lot more beds that are not being counted but the basic fact is that just in terms of state hospital beds Minnesota ranks 49/50 states.

There was a Forensic Assertive Community Treatment (FACT) team representative there as well. There are currently 56 ACT teams in 43 counties in the state of Minnesota. There are approximately 90 patients per team. The FACT team specializes in seeing patients with severe mental illness who also have probation officers. The leader that team talk briefly about forensic cognitive behavioral therapy (CBT). Therapy focuses on a number of maladaptive cognitions that typically promote repetitive criminal behavior. One example was the error of “super optimism” or “negative consequences of this behavior do not apply to me”. Since the therapy for repetitive criminal behavior is generally considered futile to try to locate literature on this type of therapy but was not successful. The psychiatrist who headed the FACT team also talked about the importance of “felony-friendly housing” and “felony-friendly supportive services”. Both of the social features are critical for stabilizing people in the community but these resources are rare.

On the darker side there were presentations from both the MN Department of Human Services and managed care representatives.  Not a great deal of detail was provided by DHS.  They briefly described improvement in the physical environment of their forensic units.  They gave the current bed capacity of Anoka Metro Regional Treatment Center (AMRTC) – the largest non-forensic state hospital.  They described the number of facilities for the treatment of psychiatric and substance use disorders as including AMRTC, 6 much smaller Community Behavioral Health Hospitals (CBHHs), 5 Community Addiction Recovery Enterprise (CARE) programs, and 4 Minnesota Specialty Health System (MSHS) Programs.  AMRTC has a 96-bed capacity and has been under significant stress since a Priority Admission Statute allowed county sheriffs to send patients who were incarcerated but mentally ill as direct admissions. That results in longer lengths of stay for committed patients in community hospitals.  Compared with previous statistics provided by Kylee Ann Stevens, MD - Chief Medical Officer, Minnesota Department of Human Services, the bed capacity at AMRTC has decreased from 110 to 96 beds.  A newer Child and Adolescent Behavioral Unit is being built but there is no net increase in bed capacity.  There was no comparable data to the January 2018 post beyond that.

The DHS presentation emphasized the 40% of the patients at AMRTC Did Not Meet Criteria (DNMC) to be there. As a Medicare PRO reviewer for Minnesota and Wisconsin one of my jobs was to review patient stays in their hospitals and determine if they were actively being treated or it was more of a rehabilitative stay. The point at which clear progress was not occurring was an endpoint beyond which hospital care was no longer covered. The problem is that this is an almost totally subjective determination in patients with chronic mental illnesses.  If for example a person is highly aggressive and no medical treatments have worked – is that an acceptable end point to say they should no longer be hospitalized. I don’t think that it is. I have concerns about the robustness of the 40% figure for DNMC.  They presented some graphs of a Continuous Improvement Project that increased patient flow and decreased the DNMC to 19%.  Some external validation that large community acute care hospitals like Regions and Hennepin County medical Center were noticing the effect of this project would have been useful.

DHS also presented a few slides about “innovation” within the system.  They discussed Lean Six Sigma training as adding value in that it provides business skills to clinicians and leads to innovation. I remember they told me the same thing when we got that training in the managed care company where I worked. The problem is that managed care companies don’t really want to hear any ideas from physicians at least none that are not reflected back from management.   There were three bullet points on Michael’s Game, Ligature Mitigation, and Harnessing the Power of the EHR.  They suggested the Michael’s Game was useful to treat delusions for the purpose of competency restoration.  The only available literature I could find suggests it is useful to try cognitive behavioral therapy (CBT) in people with psychosis, especially if there is little familiarity with the technique. Ligature Mitigation is basically a Centers for Medicare & Medicaid Services (CMS) mandate to ensure the safety of the inpatient environment by policies and environmental inspection.  It seems more like a requirement than innovation.  In terms of the power of the electronic health record – I think there is finally a consensus that it is more of a burden than anything else. If there is some power there within the state hospital system – please demonstrate that.

There were a number of other speakers from the managed care industry and affiliated organizations.  There were diagrams about patient flow in the ED and what service availability can do to reduce ED congestion.  There were no inpatient psychiatrists there. The people with the most insight into the problem were absent.  After being an inpatient psychiatrist myself for 22 years I thought about why that might be.  Inpatient docs after all are subjected to all of the unrealistic expectations of everyone else.  Toward the end of my inpatient career I was being sent patients with severe medical problems and either no psychiatric disorders or stable psychiatric disorders.  I was getting these folks because everybody knew that they would get the care they needed – and the case managers who were ordering hospitalists to discharge people would be out of the loop. Inpatient psychiatry became a place where in addition to acute care psychiatry – everybody’s problems could be worked out there. And I had the added advantage of a case manager sitting in my team meeting reporting back to administrators on whether I got people out in 4 or 5 days.  The discharge process was intolerable because there were no discharge resources.  The availability of state hospital beds and group home beds were all shut down by many of the agencies represented in the room. Managed care was responsible for the intolerable work environment and a policy of discharging people before they were stable in order to optimize billing.  Basically, many of the people in the room who created the problem were now saying they could solve it. And I have heard these refrains for the past 20 years.

In a form of ultimate irony, there was a rumor at the meeting that one of the Twin Cities metro hospitals was going to be shut down by the managed care company that owned it taking another 105 psychiatric and substance use beds off line.  Since this question entered the Q & A session it seemed more than a rumor.  There was no comment from the managed care people.  

Besides the ACT psychiatrists there was another bright spot.  Dave Hutchinson, the Hennepin County Sheriff described the progress he was making at the policing level. Deputies were getting crisis intervention training (CIT). He made the point that I think a many don’t consider – crisis calls about obvious psychiatric problems that are being observed by the public go to the police twenty-four hours a day. He described the toll on the police including the statistic that 80% of officers who are involved in the use of deadly force – never return to work.  The jail in Hennepin County – like everywhere is inhabited by a large number of people with mental illness. Sheriff Hutchinson was very clear about the fact that this is a suboptimal situation and he would prefer that these people are in settings where they can get adequate care.

At the end of the session, I met briefly with one of my former residents.  She was a panelist for the meeting. She asked me what she was missing: “It seems that all indications point to needing more beds.”  I reassured her that she didn’t miss a thing.  It was the elephant in the room.  I have seen two decades of smoke and mirrors about why more beds aren’t necessary. It doesn’t seem that the state of Minnesota is any closer to recognizing that this is a real problem. It doesn’t seem that professional psychiatric organizations are any closer to confronting managed care or opaque state bureaucracies about how they are at the minimum unhelpful to people with serious mental illnesses and at the maximum harmful.

    

George Dawson, MD,

References:

1:  Simpson SA. A Single-session Crisis Intervention Therapy Model for Emergency Psychiatry. Clin Pract Cases Emerg Med. 2019;3(1):27–32. Published 2019 Jan 10. doi:10.5811/cpcem.2018.10.40443D

2: Khazaal Y, Favrod J, Libbrecht J, et al. A card game for the treatment of delusional ideas: a naturalistic pilot trial. BMC Psychiatry. 2006;6:48. Published 2006 Oct 30. doi:10.1186/1471-244X-6-48.   

3: Melnick ER, Dyrbye LN, Sinsky CA, et al. The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among US Physicians [published online ahead of print, 2019 Nov 12]. Mayo Clin Proc. 2019;S0025-6196(19)30836-5. doi:10.1016/j.mayocp.2019.09.024



Supplementary:

There are many estimate of optimal bed numbers and Minnesota does not come close on a number of them.  The Treatment Advocacy Center has a number of documents on their site that list Minnesota as 40/50 in 24 hr hospital inpatient and rseidential treatment setting beds, 41/50 in inpatient beds, and estimates that the state needs to add 1,165 beds to the system to establish an adequate base rate of available beds.

This document from the Pew Charitable Trust looks only at state hospital beds and shows Minnesota at 3.5 beds per 100,000 population with a ranking of 49/50 states.  

At least two panels of experts have concluded that 50-60 publicly funded beds per 100,000 is necessary to provide the same level of medical services and wait times for psychiatric patients in emergency departments as medical/surgical patients.