Hundreds of Minnesotans with mental health problems are languishing in hospital psychiatric units for weeks, even months, because they have nowhere to go for less intensive care, according to a comprehensive study to be released this week.
As a result, private hospitals are absorbing millions of dollars in unreimbursed costs, while patients who are well enough to be released are being deprived more appropriate care at a fraction of the cost.
The study, by the St. Paul-based Wilder Foundation, is the first statewide analysis of delays in the discharge of psychiatric patients from private hospitals, and it highlights deep and dangerous flaws in Minnesota's system for treating people with mental illnesses. The study is expected to be closely read by key legislators, as it comes just weeks after Gov. Mark Dayton's task force on mental health held its first meeting to develop recommendations for mental health reform.
Researchers found that nearly one in five psychiatric patients in Minnesota are stuck in hospital beds even after they are stabilized and ready for discharge, because of bureaucratic delays and a severe lack of other treatment options. That amounts to nearly 50,000 potentially avoidable hospital days a year, according to the study of 20 hospitals. On any given day, about 130 patients across the state are sitting in psychiatric beds who do not need that level of hospital care — occupying beds that could be used by patients facing dire emergencies, the study found.
The bottlenecks are straining Minnesota's hospitals, causing overcrowding in emergency rooms and leaving fewer beds for new patients. In some cases, mental health patients wait on stretchers in hallways, or are sent as far away as Fargo or Sioux Falls, because local psychiatric beds are already full, say hospital administrators. "This is, by far, the most pressing public health crisis in our state," said Dr. Rahul Koranne, chief medical officer for the Minnesota Hospital Association, which commissioned the study.
Nils Peterson, 47, who is diagnosed with bipolar disorder, said he is still baffled about why he was confined to a psychiatric unit for nearly three weeks earlier this summer.
Peterson, a nurse from Rochester, said he was taken to the Mayo Clinic in June while in the throes of a psychotic breakdown, which he says was largely triggered by a decision weeks earlier to stop taking his medications.
Over the course of a few days, he became increasingly manic and delusional, convinced that he was on the verge of producing a blockbuster Hollywood film. He began calling and e-mailing friends and relatives as far away as California, urging them to send money for his grandiose film project. "I really got swept up in some out-of-this-world thinking," he says. "There was no question I was sick and needed help."
Even so, Peterson said he quickly stabilized once back on his regular medications, and then simply needed a supportive environment to recuperate. Instead, he was kept on a locked psychiatric unit for 20 days, with little to do except flip television channels and go on solitary walks to the bathroom.
"I was getting angrier and angrier each day that I was there," said Peterson, who is now living at in a transitional home in Rochester.
Though complaints of patient-flow bottlenecks have abounded for years, the Wilder study offers the broadest and most detailed analysis yet of the scope and causes of the problem. During the 45-day period under study, 19 percent of days spent in psychiatric beds were "potentially avoidable" — meaning the patient had stabilized and was eligible for discharge but had nowhere to go.
The delays underscore how psychiatric treatment differs from other forms of medical care. "What would our communities say if we said cancer patients could not get to a tertiary care center to provide cancer care? ... Would we just sit silent like we have been for some years with mental and behavioral health?" asked Dr. Koranne. "No, we wouldn't."
The reasons for prolonged hospital stays are varied and complex, and point to the need for systemwide reform, say hospital administrators. The two most common reasons for discharge delays were a lack of available beds in state-operated facilities and system delays in processing patients. Other leading causes were a lack of beds at chemical dependency treatment centers and bureaucratic delays in obtaining Medicaid benefits and civil commitment papers.
The goal of the analysis was to get beyond broad generalizations about the Minnesota's mental health system being "broken" and to identify specific gaps in care, said Dr. Paul Goering, vice president of mental health and addiction services at Allina Health, which has 300 psychiatric beds at its network of hospitals statewide. "It's been so paralyzing for the community to say, 'It looks like things are broken,' and then to say it again the next year," he said.
The study likely underestimates the scope of the problem because it counted only patients waiting in hospital psychiatric units, and not those in emergency rooms and other hospital medical units, administrators pointed out.
At Hennepin County Medical Center (HCMC), some psychiatric patients are waiting up to three months for placement in state-run psychiatric facilities. The waits are so long for the Anoka-Metro Regional Treatment Center, a state-run hospital with 175 beds, that HCMC has virtually stopped sending patients there. Last year, just 5 patients from HCMC were discharged to Anoka-Metro, down from as many as 70 patients several years ago.
While waiting for less-intensive care, many of these psychiatric patients are held in locked units with little sunlight and freedom of movement, noted Dr. Eduardo Colon, chief of psychiatry at HCMC. "Most of us have the freedom to come and go," he said. "We don't understand how difficult that is to be confined to a locked space with locked doors."
Frustrated by legislative inaction, some large hospital systems are already taking steps of their own. Both Mayo Clinic and HCMC are developing short-term "recovery homes" for psychiatric patients who may be ready for discharge from the hospital, but need more therapy before returning to their own homes. Other hospitals are working with counties and the state to develop more 16-bed intensive residential treatment centers for patients transitioning back into the community after a hospital stay.