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Changing rooms: Emergency departments adapt to address mental illness

Waterloo-Cedar Falls Courier - 8/30/2016

Aug. 30--Third in a series

WATERLOO -- Not a single day goes by without emergency departments in the area taking in a patient in mental health crisis. It can be as few as two to three in 24 hours, or as many as a dozen.

There's fierce debate as to whether people with mental illnesses are on the rise or just better recognized. Schizophrenia rates, for example, have remained stable, while depression and anxiety appear to be increasing. Regardless of the reason, emergency departments staffs have updated their best health practices.

"They're not used to having people in their department for hours on end, and that may be the case with a behavioral health patient if we can't find a bed," said Chris Latta, interim director for behavioral health at Covenant Medical Center.

Both Covenant and UnityPoint Health-Allen Hospital are adapting their emergency departments because of those behavioral health patients. Covenant already has a secure area within the emergency department for those patients so they cannot harm themselves or others. Allen is creating that safe space, while recognizing additional sanitary needs for a longer stay.

Both hospital organizations also have brought in behavioral health consultants to assess and begin treatment immediately. Peoples Community Health Clinic has a similar position for any of its patients needing mental health help.

As they adapt, the hospitals and clinics see, better than most, the service gaps. They feel first-hand the crunch of constricting bed space.

Lack of beds

The stresses on the emergency departments created by a lack of bed space for crisis intervention services, particularly for youth who may face a much longer wait than adults, is one of the top five gaps being addressed by the Cedar Valley Mental Health Planning Coalition that's facilitated by the local United Way.

Both Covenant and Allen have mental health units. Covenant has 16 adult psychiatric beds and four adolescent beds for children 12 and older. Allen has 21 beds for adults, including people 16 and older. Sartori Memorial Hospital in Cedar Falls also has a 15-bed inpatient behavioral health unit for seniors.

But both Covenant and Allen say their units, designed for shorter-term care, are full the vast majority of time.

They're filled with both patients who come from their hospitals as well as hospitals from across the state. Latta estimates about 60 percent of Covenant's beds are occupied regularly by people from outside hospitals.

"It's entirely situational," Latta said of how long a person stays in the emergency department until a bed is found. "Historically, weekends, you have just about as high of a likelihood of winning the lottery as you do finding a psych bed in the state of Iowa."

While they attribute much of the bed strain to the closure of two of the state's four mental health institutions, it alone does not account for the increased need. Iowa Department of Human Services spokeswoman Amy McCoy said the transfer of patients to beds across the state happened before the closure.

She also noted a statewide system regularly shows vacancies in the 730 public and private beds serving adults and children available in the state, a situation many area providers dispute.

Area providers say the system is rarely current and doesn't distinguish between types of beds, as in it may show vacancies in the Cedar Valley when only the senior unit has openings.

Provider gaps

When it comes to providers, Iowa ranks 47th in the nation for its number of psychiatrists and psychologists. It also ranks 44th in mental health workforce availability.

"As we look to the top five, we know that we can't really make a difference in those areas, unless we, at the same time, are working on some of these obstacles," said Debbie Roth, of the Cedar Valley United Way, who leads the planning coalition with former county public health director Bruce Meisinger. "And the most prevalent and impactful obstacles were the lack of providers."

Covenant has a hospitalist who fills the role of a psychiatrist, though it has been recruiting for the latter for years. The demand for mental health services at Peoples Clinic has led the agency to seek a psychiatrist for the past year and a half; it has the grant funding in place but can't find anybody to fill the role.

Sharon Duclos, adult medical director at Peoples Clinic, credits Black Hawk Grundy Mental Health Center with accessing mental health care for clinic patients. But Black Hawk Grundy executive director Tom Eachus struggles to find providers.

He currently relies on four psychiatrists who provide services through video chats, a service called telehealth. Three of the four live outside the state, but all are licensed to practice in Iowa.

Eachus said it's helped cut the wait time for services from months to weeks, and about 85 percent of the center's clients have no problem with the service.

The gaps help make mental health drive up overall health care spending.

Jeff Wilkins, a physician in Allen Hospital's emergency department, and Duclos said the patients who are most difficult to treat are those who have a mental illness and a second physical medical condition.

"We know that those patients can have a concomitant mental health diagnosis are twice as likely to visit the ER, use eight times as much resources in the dollar amount as someone who does not have a concomitant mental health diagnosis," Wilkins said. "It's a huge driver of health care."

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