Lack of psychiatric beds burdens health care system

From The Portland Business Journal, February 5, 2006

Urgent-care patients from Portland get sent to facilities

Over a recent holiday weekend, three Portland-area patients needing emergency mental health care were sent out of town for help. One patient ended up in a Medford hospital; the other two went to Corvallis.

The reason: Not one Portland-area hospital with psychiatric units had beds for these acutely ill patients.

Unfortunately, such out-of-town transfers are routine, say area mental health workers and advocates.

Almost every week, hospital emergency rooms in the Portland area send psychiatric patients — people who are suicidal or hallucinating, for example — to hospitals in Salem, Eugene, Corvallis, Pendleton, Bend, Medford or Coos Bay.

“There aren’t enough psychiatric beds in the city to handle the amount of people needing them,” says Jean Dentinger, supervisor of the involuntary commitment program in the behavioral health division of Multnomah County’s Department of Community and Family Services.

“It’s an inefficient and expensive way to provide care,” she says with frustration. “It’s not good care for patients to sit in an emergency department in Medford. We don’t like it, they don’t like it and the hospitals receiving them aren’t happy either. But it’s the system we have.”

A combination of funding cutbacks, steep cuts in the Oregon Health Plan, rising health care costs and an increasing number of uninsured Oregonians have all contributed to what has become a crisis-level shortage of beds for mental health patients in metropolitan Portland.

Since 2001, the metro area has lost nearly 200 psychiatric beds, beginning with the closures of Pacific Gateway Hospital in Southeast Portland and the Providence Crisis Triage Center. That same year, Oregon Health & Science University Hospital shut down two mental-health units.

Two years ago, Woodland Park Hospital in Northeast Portland closed its doors, eliminating another mental health unit.

Currently, about 150 beds are available at the six area hospitals that have psychiatric units, according to statistics from Dentinger’s office. All of them fill up on regular basis.

Patients who show up at emergency rooms for care wait hours or sometimes even a day or more for placement in a psychiatric unit.

“Psychiatric patients really clog up the emergency department,” says Sue Dietderich, administrative director of emergency services for Legacy Health System. Psychiatric patients, who can be a danger to themselves or others, need special attention and one-on-one observation, all of which strains emergency departments.

“It ties up a staff member, ties up a critical-care room and is a disservice to the patients themselves,” says Dietderich.

Kaiser Permanente, which currently does not operate a mental health unit, will relieve some of the pressure on emergency rooms in the summer of 2007 when it opens a 40-bed psychiatric unit in a new building now under construction next to its Sunnyside Medical Center in Clackamas.

“We looked at what we needed to do to take care of Kaiser patients and at our community obligation,” says Keith Griffin, assistant chief of Kaiser’s mental health department.

Like other hospital emergency rooms, the Kaiser mental health unit will admit anyone needing a bed, not just Kaiser members. “We’re all in the same dilemma,” Griffin says. “Everybody is having to make sure we help each other and stretch what we do have to the max.”

On the other hand, Physicians’ Hospital in Northeast Portland — the former Woodland Park Hospital which reopened under new ownership in 2004 and is still working to become financially stable — has dropped plans to add a mental-health unit to an urgent-care facility it is building this year.

“It wasn’t economically feasible to add mental health services,” says Bill Houston, the hospital’s chief executive officer. “It would have presented a degree of staffing requirements that would make it expensive to operate. Revenue reimbursement for mental health services is terrible. We would lose money, and we can’t afford to do that.”

Houston says he recognizes the community need for such services. But, he says, “the system is broken.”

What’s needed is a full psychiatric hospital to care for patients in need of urgent care, he says.

Such a facility would be useful for providing emergency care for mental illness, agrees Herb Ozer, director of operations for Providence Health System Behavioral Health Services. However, that’s not to say that Portland or Oregon needs a major psychiatric hospital for long-term care.

Mental health providers and advocates agree that residential treatment facilities and other community resources other than a hospital would provide better and more appropriate on-going care for psychiatric patients.

Ozer says that was the idea when Dammasch State Hospital closed in the mid-’90s.

“Closing Dammasch was a good thing,” he says. “Some were in Dammasch for years who could have lived in their community.”

But the state never provided enough money to establish services and facilities for people who otherwise would have been treated at Dammasch.

And there has never been adequate funding since then for comprehensive outpatient mental health care, Ozer says.

“So we end up having to hospitalize them,” Ozer says. “We can’t get patients into ambulances for cardiac care. Or they take up hospital beds, which are not set up to be safe for suicidal patients.”

Because reimbursements for mental health patients are low, hospitals end up absorbing the cost of their care or passing it on to insured patients in the form of higher insurance costs, he says.

Mental health workers agree the bed-shortage situation is dire and needs a broader solution than adding more beds.

“It’s important not to look at it as a bed crisis, but as a system crisis,” says Leslie Ford, director of Cascadia Behavioral Health Services, which provides mental health and addiction services, assessments, a 24-hour crisis team and other services for low-income clients.

“We need more case management, more crisis intervention, more affordable and supportive housing services,” she says.

Mental health workers and advocates are meeting regularly to find solutions. More funding from the Oregon Legislature is a priority.

A group of providers has formed the Oregon Psychiatric Inpatient Committee to urge state lawmakers to step up to the funding plate.

Metro-area hospital emergency department managers are meeting once a month to share problems, discuss solutions and look for ways to cooperate with each other, says Kathleen Ramey, director of emergency services for the Portland Providence Health System.

To help alleviate the bed shortage problem at its hospitals, Legacy Health System hired a psychiatrist to examine mentally ill patients who show up in the emergency room, says Legacy’s Dietderich.

“She makes the rounds daily at Emanuel and Good Samaritan hospitals and at some Legacy clinics,” Dietderich says. “We need four of her!”

The Oregon Psychiatric Association also has taken on the bed-shortage issue, says Portland psychiatrist Dr. Thomas Dodson, the group’s president-elect. The problem will be a major topic of discussion at the association’s access-to-care summit in April.

“We know what’s necessary for comprehensive mental health system,” Dodson says. “The problem is to get funding for it and to work with local communities to make that happen.”