[F]or several years, Vermont hospital administrators have been making physical changes in their emergency departments to handle an increasing influx of mental health patients.
But it now seems clear that renovation isn’t enough.
Brattleboro Memorial Hospital is one of several facilities adding emergency room staff who specialize in mental health treatment, filling a gap in departments that traditionally have been focused only on physical health.
The changes add costs at a time when some hospitals are struggling. But Steve Gordon, Brattleboro Memorial’s president and chief executive officer, said there’s no choice but to make the investment as patients with mental health needs continue to flood emergency rooms.
“I think it’s reality. I don’t think it’s going to go away,” Gordon said. “It’s a societal issue that’s here.”
The problem of mental health patients stuck in Vermont emergency departments is not new, but it is intensifying.
A few months ago, the Vermont Association of Hospitals and Health Systems produced data showing that the number of days mental health patients spent in emergency rooms rose to 4,037 in 2016 – a nearly 29 percent increase from the year before.
That count jumped to 5,237 days in 2017, representing a nearly 30 percent increase from 2016.
There also were troubling trends within that data: For example, the number of same-day discharges for mental health patients declined as the number of multi-day stays in emergency rooms increased.
The issue is multifaceted, but one problem is that the state does not have enough inpatient mental health beds. There’s a proposed plan to add inpatient capacity in Berlin and Brattleboro, but any significant changes are likely several years away.
In the meantime, hospitals will continue to feel pressure. Gordon said about 10 to 12 percent of Brattleboro Memorial’s 14,000 annual emergency department visits are related to mental health or substance use issues.
“Probably seven or eight years ago, we were maybe around 5 percent,” Gordon said.
“What’s really changed is the acuity – the severity of the illness has really increased,” he added. “More of those patients that we see are requiring inpatient hospitalization at a psychiatric facility.”
If a psychiatric bed is not available elsewhere, mental health patients are stuck in hospitals’ emergency departments. In Brattleboro, Gordon said the longest such stays have lasted 30 to 35 days, while other patients remain for only one or two days depending on the circumstances.
Many other mental health patients are quickly stabilized, discharged and referred for outpatient treatment. “The (Brattleboro) Retreat is our second largest source of outpatient referrals, after Dartmouth-Hitchcock Medical Center,” Gordon said.
Emergency room stays represent wasted time and further pain and suffering for mental health patients, who are not getting the treatment they need in a traditional hospital setting. And hospitals incur additional costs, regulatory troubles and an increased risk of safety problems.
In an attempt to address those safety issues, some hospitals have invested in enhanced emergency room facilities. Examples of such projects have included upgrades at Rutland Regional Medical Center and at Grace Cottage Hospital in Townshend, where administrators added a “safe room” for mental health patients by relocating the emergency department’s waiting room.
Recent emergency department renovations in Brattleboro included the addition of movable walls in three rooms in order to “protect anybody from either hurting themselves or hurting others with the (clinical) devices on the walls.”
“We also created a safe room, as well, for more agitated and more violent patients,” Gordon said.
But there’s no substitute for manpower and expertise. So a few weeks ago, Brattleboro Memorial hired a psychiatric nurse practitioner to specialize in mental health and substance use issues in the emergency department.
Brattleboro Memorial already had been offering remote telepsychiatry services to patients, whereby psychiatrists from the Retreat and from Dartmouth-Hitchcock offer consults from remote locations. But Gordon said it was important to have a physical presence in the emergency room, as well.
“The challenge is, most (emergency departments) have been based on medical-surgical care,” Gordon said. “Now, all of the sudden we’re seeing a very substantial increase in mental health and substance use. And we’ve got to help our physicians and our associate providers … to deal with these kinds of situations, where it hasn’t necessarily been in their education or training.”
Gordon said it makes sense to have the new nurse practitioner focus on both mental health and substance abuse, given that the two issues often are co-occurring.
It means Brattleboro Memorial can prescribe Suboxone – a drug used in medication-assisted addiction treatment – in the emergency room. The nurse practitioner also will help ensure that patients are connected to Suboxone prescribers in the community, Gordon said.
Brattleboro isn’t the only hospital seeking help with mental health staffing.
Rutland Regional, Central Vermont Medical Center, University of Vermont Medical Center and Northwestern Medical Center all have either added staff or are working with designated mental health agencies in their areas to bolster emergency room offerings, said Judy Stermer, spokesperson for the state hospital association.
Northwestern, located in St. Albans, has an “embedded mental health crisis worker” and also has started a mental health training program for employees, Stermer said.
“We know that hospitals are making staffing investments to address the needs of patients struggling with mental illness in (emergency departments) around the state,” she said.
That’s both a good thing and a bad thing, said Rep. Anne Donahue, R-Northfield.
Donahue, a longtime mental health advocate, has a complex perspective on the issue. In addition to her work as a legislator and vice chair of the House Health Care Committee, she’s also interim executive director of Vermont Psychiatric Survivors, a statewide advocacy group.
Adding mental health services in emergency rooms could be seen as “institutionalizing a problem,” Donahue said, given that many of those patients shouldn’t be stuck in emergency settings to begin with.
On the other hand, hospitals’ responses to the problem are “really good, because the reality is what it is right now,” Donahue said.
Another question – What took so long for hospitals to respond to the crisis? – also is a complex matter, Donahue said.
She doesn’t buy the notion that additional staffing costs are an excuse. “Providing appropriate care for people who come to your hospital always costs money,” Donahue said.
But she said it has taken time for Vermont’s mental health system to recover from Tropical Storm Irene in 2011, when floodwaters closed the state’s psychiatric hospital in Waterbury.
For a time, the response was “very short-term, crisis-oriented,” Donahue said. “Now I think there’s a recognition that, as we look at longer-term solutions, it’s going to take a while.”
Gordon acknowledged the importance of taking a broader look at the problem. He said he’s involved in a new working group that includes the Retreat, Brattleboro police, town officials and Health Care & Rehabilitation Services.
The key question, Gordon said, is “what else can we do from a systems standpoint so that we don’t have these patients necessarily coming to the ER first?”