Marnie Jansen's breaking point came the night a psychotic patient threatened to stab her in the stomach with loaded syringes, then tore the ID badge from her uniform and used it to escape from the locked psychiatric hospital in Rochester where she worked. ¶ Everything turned out all right that time: The patient returned voluntarily and soon calmed down.
But for Jansen, a registered nurse, it was the last straw. She quit. "I was very scared," she said. "I was six months pregnant."
The hospital where Jansen worked is one of 10 small psychiatric facilities Minnesota opened two years ago across the state. It was part of an innovative effort to improve psychiatric care while reducing the cost of treating Minnesota's most difficult mental patients.
The experiment hasn't quite worked out as planned. The 16-bed hospitals have been bedeviled by assaults, patient-on-patient confrontations and other safety problems that often required them to rely on local police rather than trained staff for security. Just last month, a patient at the Fergus Falls hospital hijacked a van while in transit, triggering a chase that ended only when police crashed into his vehicle.
These problems, in turn, have raised red flags with federal regulators, stalling millions of dollars in federal funding. One of the hospitals closed and two were converted to other forms of care.
Today, state mental health officials say they are more cautious about admitting potentially aggressive patients to the community hospitals. They are also adopting a philosophy designed to improve care, avoid physical confrontations between staff and patients, and follow federal rules on the use of police.
As a result, police calls for assistance are fewer, said Dr. L. Read Sulik, assistant commissioner at the Minnesota Department of Human Services (DHS), though he acknowledged, "there was a time when we were seeing more."
Still, union leaders and some current and former employees say that staffers at the remaining seven hospitals are stuck in an impossible situation. Rules handed down in the last two years forbid them to call police except in the most dire circumstances, yet their patients are increasingly difficult and sometimes violent. Assaults against staff remain a daily risk, they say, and the annual number of patient injuries has doubled since 2008 to almost 400 so far this year.
"It's a dangerous situation," said Jim Monroe, executive director of the Minnesota Association of Professional Employees, the union that represents psychologists, therapists and other professionals at the state hospitals.
Questions about the Community Behavioral Health Hospitals are at critical juncture. Faced with a $17 million budget cut and problems at the network of hospitals, DHS is redesigning its psychiatric care network, including the much larger hospital in Anoka. It is sure to face new questions when the Legislature convenes in January.
Some professionals even question whether the small psychiatric hospitals, which cost taxpayers $37 million a year, are an appropriate place for the patients they get. Most have been committed by a court because they are a danger to themselves or others.
"The patients in hospitals are those patients who are really dangerous, potentially violent," said Michael Trangle, head of behavioral health services at Regions Hospital in St. Paul. "If their behavior was under control, they could be treated as outpatients."
A new strategy
When DHS launched a statewide overhaul of its psychiatric services in 2007, the 10 community hospitals were at the heart of a new strategy. They were designed to provide quality short-term care close to home for mentally ill people in communities such as Fergus Falls, Annandale and Baxter. Each one cost taxpayers about $4 million a year, but they replaced six big, far more expensive, psychiatric institutions that were outdated relics of another era.
They were also the first state-run psychiatric facilities designed specifically to qualify for federal payments under Medicaid and Medicare, an innovation that's been closely tracked by other states. If it worked, the state would get Washington to pay up to half the costs.
In all, they were "very reasonable and well intentioned," Trangle said.
Safety problems surfaced quickly. Unlike larger institutions, the hospitals are isolated, with small staffs and little security. Yet they accept the most difficult of all psychiatric patients, those who are hard to treat or who have criminal histories. Patients have diseases such as schizophrenia and bipolar disorder, frequently combined with alcohol and drug addiction. Most are not aggressive or violent. But some do strike out because they are at a point in their illnesses when their connection to reality is tenuous, or they can't control their emotions or their actions.
"We pointed out that it was a bad plan," said Linda Lange of the Minnesota Nurses Association (MNA), which represents nurses at the facilities.
When employees asked how they should handle emergencies, they were told: Call the police, union officials say.
And they did. In 2008, police were called more than 50 times to help the staff control aggressive, violent patients, according to DHS records.
Police chiefs say the hospitals called for assistance many more times for other reasons as well. "The police became their safety valve," said St. Peter Police Chief Matthew Peters.
Guns and Tasers
But when police officers come to a mental health facility, they don't come unarmed. They bring guns, Tasers and other weapons, and that led to a series of problems that drew the notice of both state and federal regulators.
In June 2008, police were called to the Rochester hospital to help control a delusional, elderly female patient who refused to take her medication. She was swinging her cane, and threatening to "knock your blocks off," according to a DHS internal investigative report. When she raised her arm as if to throw a water bottle, an officer fired his Taser. She collapsed and was taken to a local emergency room.
Then, according to the report, the staff asked police to help with another agitated, paranoid patient. The officer stood by while two employees held the patient and tried to give him a shot, but when he broke loose and went after the officer, he was hit with a Taser as well.
Federal officials who regulate hospitals on behalf of Medicare and Medicaid say police should be called only in emergencies, and only if the hospital staff believes the patient should be arrested. The use of handcuffs, Tasers or guns is a violation of federal guidelines, according to the Center for Medicare and Medicaid Services (CMS).
DHS officials took notice, said Sulik. Federal regulators refused to certify the facilities for Medicaid and Medicare payments as long as they relied on police for security, delaying millions of dollars in federal reimbursement. It was the "most significant barrier to certification, " Sulik said.
In the fall of 2008, DHS changed the rules, directing the staff to follow the federal guidelines on calling police.
That only created a new bind, former employees say.
"We were directed, 'You don't call 911,''' said Jan Ekert, a nurse who quit the Annandale community hospital a year ago. "I'd be reluctant to jump into a situation for fear of getting hurt. Or I would jump in and end up really getting hurt."
"They pulled that safety net out from under us," said Tracy Moore, a former nurse at the Rochester hospital.
Police calls decline
Sulik said staffers have never been told not to call police in an emergency. But, he acknowledged: "There is not an easy solution. We have to rely on [police] assistance."
The number of police calls did decline starting in 2009, but the transition has been slow and troubled. In April 2009, a suicidal patient tried to escape the Annandale hospital. When the staff stopped him, he began smashing furniture, prompting an employee to call the police. An officer fired his Taser, but the patient deflected the electrified barb with a blanket. In the following melee, the patient grabbed the officer's handgun and fired it.
"I was on top of the patient's legs,'' said Amy Batzel, a registered nurse. "The gun was a foot away from my face.'' The bullet ricocheted off the floor and into the wall. "I'm only 5-foot-1 and I can't take down a 6-foot guy,'' she said. "They could not promise me my safety."
The state Health Department cited the hospital for failing to provide a safe environment for patients, and the incident illustrates why regulators don't want police inside psychiatric facilities.
It also illustrates the critical need for teaching the staff new therapeutic techniques so they don't have to physically restrain patients -- one of the most common reasons for injuries and police calls, Sulik said.
"It's a different way of thinking around how to intervene in such a way that you deescalate a patient without having to resort to physical intervention in order to gain control," he said.
Sulik said DHS has begun an intensive staff education program and has protected the training budget despite fiscal pressures.
Now, he said, the use of physical controls on patients is declining and police calls continue to drop.
Both are "core values that most of the country is moving toward," said Kevin Huckshorn, a Delaware psychiatric expert and a leader in a nationwide initiative to improve care of mentally ill patients.
There's been another payoff as well. Today, six of the seven Community Behavioral Health Hospitals have been certified by federal regulators, resulting in $8.2 million in federal payments this year. Approval on the final one is pending.
Union officials and many employees, however, say that conditions are as worrisome as ever. The van hijacking last month in Fergus Falls was a case in point, employees say. About a week after that incident, the staff at the Alexandria hospital called police to help with a difficult patient. But before officers could arrive, the patient knocked out a nurse with one punch, according to the MNA.
So far this year, there have been 16 patient assaults on staffers -- more than the 12 in 200, and on pace to equal the 20 in all of 2008. Patients injuries, too, have increased substantially -- from 211 in 2008 to 383 so far this year. State officials say they can't altogether explain the increase, but say it may stem from patients who are increasingly acute and aggressive with each other.
Meanwhile, union officials and former employees say DHS retaliates if staff members call police under duress.
In March of this year, a young female patient at the Willmar hospital was kicking staffers and disrupting other patients, according to Jule Werner, a psychiatric nurse. While other employees held the patient, Werner called a doctor for instructions. But when two other patients threatened to intervene to help the young woman, Werner called police.
"That was not the thing to do," she said in an interview. "They said that was a breach of their policy." She was afraid she would be fired, Werner said, so she took early retirement after nearly 25 years in nursing.
Sulik said no employees have been fired for calling police, adding: "A punitive culture is not effective.'' Instead, he said, DHS is trying instill a culture of learning.
Huckshorn said other hospitals and mental health systems have encountered similar problems when trying to implement new standards of care, which, she said, take a lot of time and resources. Minnesota's small community hospitals are a new model, she said, and DHS needs time "to work out the glitches."
"This is massive culture change," she added. "With no extra money and staff it's almost impossible. I have to laud Minnesota for doing it."
Josephine Marcotty • 612-673-7394