Late on a snowy evening in March, the normally tranquil cul-de-sac where George Daly lives with his wife and daughter in Minnetrista came to resemble a crime scene.
There was a police squad car with flashing lights, an ambulance with sirens blaring and a small crowd of anxious neighbors staring from their snow-covered doorsteps. All eyes were fixed on George Daly's 18-year-old daughter, Ashley, who suffers from bipolar disorder and had fled her home in a manic state. She was now walking calmly to the ambulance.
"It seemed excessive," Daly, 74, said of the emergency response. "My daughter was not a danger to herself or anyone else."
But the Dalys had little choice in the matter. In Minnesota, as in many other states, a patient who suffers a mental-health crisis often faces the added indignity of being taken to the emergency room in an ambulance or the back of a police car — even when there is no public safety risk. The experience can aggravate the patient's trauma by alerting neighbors and friends to a mental illness they would rather keep private.
Now, a number of hospitals and local officials across Minnesota are experimenting with ways to transport mental health patients in a more dignified manner, such as unmarked vehicles with plainclothes paramedics. They aim to reduce the stigma associated with a psychiatric crisis while also reducing the enormous cost of sending ambulances long distances. In addition, these alternatives could ease the pressure on local fire departments and police, who spend thousands of hours each year transferring psychiatric patients who pose little or no safety risk.
Allina Health, which owns Abbott Northwestern and 11 other hospitals statewide, now keeps an unmarked Ford Escape among its fleet of ambulances at its emergency medical base in Mounds View.
At least twice a day, an Allina community paramedic uses the vehicle to conduct home checkups on patients who recently have been released from psychiatric care or takes them to appointments. Apart from the plastic partition behind the driver, the car is indistinguishable from any other sport-utility vehicle on the street.
For now, Allina is footing the bill for these nonemergency visits, in the hope that it will reduce costly readmissions to its emergency rooms. Allina has found that about 25 percent of patients who suffer a mental-health incident return to the hospital within a month of discharge, typically because of missed appointments and other barriers to follow-up care.
"Our first priority is to serve the patient, and that means not advancing the stigma," said Dr. Paul Goering, a lead psychiatrist at Allina Health.
A need for alternatives
The concept of nonemergency medical transports is not entirely new. For the past six years, the Yellow Medicine County Sheriff's Department in southwest Minnesota has been using an unmarked Chevrolet Malibu to transport psychiatric patients from the hospital emergency room to mental-health facilities across the region.
But in recent years, as the shortage of hospital psychiatric beds became more acute, local officials have been pressed to find alternatives. Now, local emergency crews often have to transport mental-health patients hundreds of miles to the nearest facility with vacant beds. As a result, paramedics and local police are effectively out of service for hours at a time and unable to respond to more urgent emergencies.
In Virginia, Minn., the need for alternatives has "reached a crisis point," said Dan L'Allier, the local fire chief.
On some days, up to a third of the department's nine-person paramedic staff is transporting mental health patients who pose no safety risk, rather than responding to real emergencies, L'Allier said. These ambulance crews can be gone up to 10 hours at a time taking patients from northern St. Louis County to hospitals as far away as Marshall, Thief River Falls or Fargo, N.D. To free up paramedics, the Virginia Fire Department is now exploring the possibility of hiring private security guards in unmarked vehicles to move people suffering from psychiatric crises.
The main obstacle to many of these experiments is that insurance companies and government-funded programs such as Medicaid reimburse people for ambulance trips but not for private security guard transports, L'Allier said.
This spring, the Minnesota Legislature took a major step to address the problem by creating a special class of nonemergency transports under state law.
Advocacy groups plan to ask state lawmakers to include nonemergency transport as a reimbursable expense under Medical Assistance, Minnesota's version of Medicaid.
"Currently, about the only option [is] a police or sheriff or tying someone in a gurney in an ambulance," said Sue Abderholden, executive director of the Minnesota chapter of the National Alliance on Mental Illness. "None of those involve transporting people with dignity."