Portland hospitals increasingly dump psychiatric patients in long-term ER beds

Willamette Week, July 16, 2014

One of the rooms in Legacy Emanuel's ER used for psychiatric boarding.

One of the rooms in Legacy Emanuel’s ER used for psychiatric boarding.

Jennifer Ann has found herself in Portland emergency rooms more than two dozen times in the past 20 years—almost always for the same reason. 

“Usually I go,” she says, “because I feel I’m going to kill myself.”

On good days, Jennifer Ann, 56, is a high-functioning mother of four. She’s a lifelong Portlander with bobbed hair and a self-deprecating wit. She’s held administrative positions in the wood products industry, and now works as a mental health advocate. 

On bad days, Jennifer Ann (who asked that WW not use her full name) is helpless as schizoaffective disorder—a combination of bipolar disorder and schizophrenia—takes over. Last September, she went to the ER at Providence Portland Hospital at Northeast 47th Avenue and Glisan Street during a crisis. Hospital staff loaded her onto a gurney and lodged her in a stark room for 44 hours without therapeutic services.

“It’s the worst thing you can do to a person in crisis,” she says. “You just put them in a room and leave them there with minimal contact. It’s scary and depressing.”

What Providence did happens at Portland ERs all the time: Psychiatric patients held for days because there is no place to send them. Doctors and medical journals call it “psychiatric boarding.” Patients and mental health advocates call it “warehousing” or “dumping.”

“It’s a broken system,” says Cindy Scherba, clinical director of behavioral health services at Oregon Health and Science University.  

The hospitals say they have little choice. Doctors, patients and mental health advocates say the practice is an unintended consequence of the state’s flawed mental health policies.

The U.S. Department of Justice, which has been monitoring Oregon’s mental health system, criticizes the practice. Documents show state leaders have created an expensive approach that treats too few patients and leaves many more stranded in ERs.

“There’s a lot of money in the mental health system, but it’s not being spent wisely,” says Jason Renaud, a board member of the Mental Health Association of Portland. “We’ve chosen the most expensive, least effective method of dealing with people in crisis.”

Nonetheless, boarding is the default treatment for thousands of patients who come to Portland emergency rooms each year. Nobody tracks the exact number, but statistics that do exist show the problem is getting worse.

The Oregon Health Plan paid to treat 15,407 patients for mental illness at emergency rooms last year—a 47 percent increase since 2009.

Meanwhile, the time such patients spend held in ERs is lengthening.

The typical patient with a physical complaint who comes to Legacy Emanuel Medical Center’s ER in North Portland, for example, is in and out within 2½ hours.

Emanuel’s median ER stay for psychiatric patients in May was 40 hours—more than twice what it was a year ago.

“There’s not a system of community alternatives for people in distress,” says Beckie Child, a patient advocate who teaches in Portland State University’s School of Social Work. “Right now, the only option we have is the ER.”

The parade of psychiatric patients to emergency rooms began 60 years ago with a national policy of deinstitutionalization. The theory was that moving patients from hulking mental hospitals into their communities would produce better outcomes.

Institutions opened their doors, but state and local governments have struggled to find community-based alternatives.

Typically, a patient who arrives at an ER suffering a psychiatric crisis gets evaluated by a doctor. The patient may elect to remain voluntarily until an inpatient bed is available, or a doctor may order an involuntary “psychiatric hold.” In the latter case, a county investigator must assess within three days whether the patient should be committed. A commitment hearing must then be held within five business days. 

Without local beds, patients are typically put into what have become improvised holding cells in hospital ERs. For safety, that space typically contains no furniture other than a bed bolted to the floor. The patient is in a netherworld: not free to go, not admitted, and often not treated. 

“Some folks end up being boarded for as long as three weeks,” says Liz Wakefield, a lawyer with Metropolitan Public Defenders who handles commitment hearings.

Nicole Currier says that boarding patients in ERs often makes their conditions worse.  

That’s what Currier, 31, says happened to her in 2011. A Northeast Portland native who loves the Woodsman Tavern and her pit bull-greyhound mix, Sadie, Currier has been diagnosed with PTSD. She says she had just been put on a new drug called Luvox that caused her to experience mania and to consider cutting herself.

Her fiance called police for help, and an officer drove Currier to the Providence Portland ER, where medical staff placed her in an ER triage room, with a guard outside the door. Later, she was moved to a locked room within the ER. 

“It was in no way therapeutic,” Currier says. “I felt like a caged animal.” 

Currier says she was in a fog. Her fiance implored hospital staff to take her off Luvox, and her condition rapidly improved. Currier says she thinks if she’d been seen by mental health specialists, the results would have been much better. 

“It felt like I went somewhere seeking help and, instead, I was punished,” Currier says. “I was on a psychiatric hold, but I was not in a psych unit. That’s very confusing.” A Providence spokesman was not available for comment.

Key decisions by state leaders in the past decade have turned Portland emergency rooms into warehouses. 

First, despite the national trend toward deinstitutionalization, the Oregon Legislature, led by Senate President Peter Courtney (D-Salem), has doubled down on building big, centralized mental hospitals. 

Led by Courtney, lawmakers voted in 2007 to replace the decrepit 125-year-old Oregon State Hospital in Salem with a new facility, plus build another state hospital in Junction City, 17 miles north of Eugene—both far from the Portland area.

State hospital beds are increasingly taken up by forensic patients—persons judged guilty of a crime except for insanity or found incapable of aiding in their own defense at trial. Such patients comprise 400 of the state hospital’s 601 patients. That leaves little room for patients from outside the criminal justice system.

“The state hospital is more and more clogged,” says Dr. Tony Melaragno, Legacy’s vice president of behavioral health administration. “For a patient who’s been committed, the wait list is increasing; it’s three or four weeks now to get a bed.” 

What’s worse, the new Oregon State Hospital is extraordinarily expensive—it costs $345,000 a year to keep a patient there, and that money comes out of the state’s general fund. 

By comparison, community-based mental health treatment—which the state lacks, requiring patients to be held in ERs for days at a time—costs $15,000 a year. And such costs are largely reimbursed by the federal government.

Oregon’s reliance on the state hospital is a sore point for federal officials. The U.S. Department of Justice has ordered the state to improve its mental health system. 

“Movement from an institution-based system and a subsequent reinvestment into a community-based system will result in major savings,” the DOJ said in a January report. 

The state’s reliance on an expensive system that’s leaving mental patients stranded in hospital ERs enrages many advocates.

“The Oregon state legislature is to blame for underfunding mental health and for mismanaging the money they do have,” Renaud says. “It’s a jobs program to Peter Courtney, and he’s supposed to be a mental health advocate.”

Courtney says he’s indeed a strong advocate. He says he has pushed to fund a wide variety of community-based options, but says Oregon will always need a state hospital.

He says replacing the existing facility in Salem rather than in Portland minimized disruptions and that the Junction City facility will serve the rest of the state outside the Willamette Valley. He notes the Junction City hospital has been downsized from a planned 360 beds to 175.

“I’m not ashamed of what we’ve done at the state hospital,” Courtney says. “I do agree that community mental health is where we need to pour it on right now. We need to elevate that effort.”

Pamela Martin, the state’s director of addiction and mental health services, acknowledges boarding is a big problem. 

She says, however, the Legislature in 2013 allocated $60 million over the next two years to add mental health services in communities.

The money will not pay for new inpatient beds, but it’s intended to prevent many of the triggers that cause people to seek emergency help. The funding will cover the costs of more crisis response teams, for example, and provide earlier treatment for people developing mental illness.

“The Legislature has made an extraordinary investment in the mental health system,” Martin says.

Private psychiatric hospital beds are disappearing rapidly. The primary reason: economics.

At OHSU, each psychiatric hospital bed loses about $500 a day. That’s because many patients lack insurance, and Medicaid reimbursement is far less than the cost of services.

“It’s just not sustainable,” says OHSU’s Scherba.

Conditions in Oregon are worse than in nearly every other state. Oregon now ranks 47th in the country for private hospital inpatient psychiatric beds, according to the American College of Emergency Physicians. Five years ago, Oregon had 28.8 psychiatric beds per 100,000 people. The rate is now to 8.7 per 100,000.  

The flood of psychiatric patients keeps coming. Last year, Portland police dropped off 1,138 patients at ERs and took only 50 to community-based treatment centers.

That reliance on ERs troubles Oregon’s federal overseers.

“Treating an individual with mental illness or in a mental health crisis in an emergency room is the most expensive form of treatment,” wrote Judy Preston, a civil-rights lawyer with the U.S. Department of Justice overseeing Oregon’s mental health system, in a Jan. 24 letter to state officials. “And one that also runs the increased risk of institutionalization and does not provide the services necessary for the prevention of future crises.”

Even in the face of failure by state leaders to fix Oregon’s system, there are solutions. 

One way is to go to court to force change. In Washington state, two hospital groups have successfully sued the state, arguing that boarding violates their patients’ civil rights “because it does not provide a realistic opportunity for improvement.” The Washington Supreme Court heard the state’s appeal of that case in late June.

There’s no such case currently in litigation in Oregon, but last month, a team of medical experts—including representatives from OHSU and Legacy, and Dr. Sharon Meieran, a Kaiser ER doctor—visited a model program in Alameda County, Calif.

There, police no longer drop people experiencing psychiatric crises at the closest hospital. Instead, officials established a psychiatric emergency room at John George Hospital in San Leandro.

The outcomes, according to a study published in the Western Journal of Emergency Medicine in June 2013, are remarkable.

Patient boarding time declined from an average of 10 hours to less than two. And because patients received appropriate treatment rather than simply being warehoused, the need for inpatient hospitalization decreased by 75 percent.

“It’s pretty incredible what they’ve done,” says Meieran. 

The economics are far better as well. 

MediCal, the California equivalent of the Oregon Health Plan, pays for up to 23 hours of treatment at John George with Medicaid dollars. 

That Medicaid billing code exists in Oregon, but nobody’s using it. 

Legacy and OHSU are pressing state officials to activate the billing code in Oregon. The two hospital systems, often competitors, have identified space in central Portland in which they hope to replicate the Alameda model next year.

“They’ve been doing it for five years down there, so it’s sustainable,” says OHSU’s Scherba. “This is probably one of the most exciting opportunities I’ve seen in my career.” 

Patients say a better approach cannot come soon enough.

Jennifer Ann, for one, is still haunted by her last experience in an ER.

“I felt abandoned and lost and frightened,” she says. “And not really having a conception of this ever having an end.”