Twin Cities hospitals have reached a breaking point under a deluge of patients with severe mental illness, who are jamming emergency rooms — sometimes for days — and being warehoused for months in psychiatric wards because doctors have nowhere to send them.
At Hennepin County Medical Center in Minneapolis, psychiatric units are full so often that delusional and unstable patients are restrained in an ER holding unit until beds open up.
At North Memorial Medical Center in Robbinsdale, a man in his early 20s has been stuck in inpatient care for seven months because there are no vacancies in long-term state facilities.
“It feels like he is an animal there,” said his mother, Trina, who spoke on the condition of anonymity for her son.
Minnesota has long had a shortage of mental health beds compared to other states — partly by design, because state officials invested in prevention programs designed to help patients avoid the need for costly inpatient beds.
But budget pressures and a recent change in state law — which gives mentally ill jail inmates priority for state psychiatric beds — have ratcheted up the pressure on hospitals.
“This is about as bad as I’ve ever seen it,” said Roberta Opheim, Minnesota’s state mental health ombudsman for more than 20 years. “People [hospitalized with severe mental illnesses] have no place to go, but they can’t just be put on the street.”
A $46 million increase in state mental health spending from the 2015 Legislature could provide some relief. It will fund crisis intervention services, intensive residential treatment centers and 15 more beds at Anoka Metro, the largest state psychiatric facility in the Twin Cities, with about 110 licensed beds. But these steps might not fully take effect for months or years. And the additional staffing for Anoka will basically restore beds that recently were shut down, officials said.
A 300-day hospital stay
Trina’s son entered North Memorial in March after a suicide attempt. The young man, diagnosed with schizoaffective disorder, has exhausted most short-term treatment options at the hospital, his mother said, and is at the top of the waiting list for transfer to Anoka.
He’s been at the top for two months, though.
“So often it just feels like he has just absolutely given up,” his mother said. “He will stay in bed for days on end, because he’s afraid he will do something dumb and be restrained again.”
Other hospitals report similar “boarders” who have exhausted short-term treatment services and linger nonetheless. Regions Hospital in St. Paul recently held a patient for nearly 300 days.
At HCMC, one in five admitted psychiatric patients would qualify for care at Anoka due to their psychiatric conditions and civil commitments. But the Minneapolis hospital no longer keeps a waiting list for transfer to Anoka because it is futile, said Dr. Ian Heath, who directs HCMC’s psychiatry services.
“We haven’t … sent anyone to Anoka since April,” he said. “They used to transfer out [to Anoka] within days of being civilly committed.”
Three HCMC workers recently contacted the Star Tribune to complain about the backlog of psychiatric care and patient treatment.
“The extremely acute patients may be held in restraints or in seclusion on and off for days, getting injected with high doses of antipsychotic medication to quell immediate mental health symptoms, while staff scramble to meet their basic needs,” wrote psychiatric nurse Karl Olson in a letter to the editor. “As a nurse in this department, I am troubled when I have to tell patient families that their loved one might not get optimal treatment for several days.”
Megen Cullen, senior director of HCMC’s psychiatry department, said she worries that such accounts might scare off patients who need care, but agreed that long inpatient stays are problematic.
“It’s not really humane for the person,” she said. “I don’t think I could do it.”
Jails under stress too
Shortages in Minnesota’s mental health system have been a recurring theme for decades. In 2007, Gov. Tim Pawlenty enacted a series of reforms that included a system to track and manage the state’s limited number of psychiatric beds. His administration launched a network of small community behavioral hospitals around the state.
Problems persisted, especially at county jails. County sheriffs increasingly found themselves locking up offenders with mental illness and unable to transfer them to Anoka for treatment.
In 2013, the Legislature enacted a “48-hour rule” requiring the Department of Human Services to move inmates to Anoka within two days of being civilly committed by a judge for inpatient psychiatric treatment.
As a result, hospitals found their patients backed up behind jail inmates, so that even severely mentally ill patients couldn’t find space at Anoka Metro.
Hospitals had transferred 253 psychiatric patients to Anoka in 2012, before the 48-hour rule was created, but so far this year have only transferred 61. Jail inmates going to Anoka increased from 64 to 103 in the same period.
In addition, patients from jails and hospitals are becoming more complex and aggressive, which has increased the average length of stay at Anoka Metro by about 20 days over the past year and decreased the ability to take new patients, said Lucinda Jesson, commissioner for the Minnesota Department of Human Services, which operates the Anoka facility.
The number of reportable worker injuries due to patient aggression nearly doubled from 24 in 2013 to 46 in 2014.
Jesson said some beds were closed down this year so staff could spend more time with high-risk patients needing one-on-one or two-on-one supervision — though legislative funding has allowed those beds to open back up.
“We are desperately trying to respond to this,” Jesson said.
Help on the way
Trina said she is frustrated with her son languishing at North Memorial, but doesn’t blame the hospital or caring staff.
Her son hasn’t been outside for seven months, other than for trips to court, so an employee tried playing soccer with him in the only available space — the room where problem patients are confined. The happiest moment for her son was building a wooden stool in occupational therapy that he could give to his niece. When he asked to make a second one, he was told only one per patient.
“I get it if he’s only going to be there for two weeks,” his mother said.
Part of the problem is an absence of “step-down” community programs that could accept patients ready to leave Anoka. Jesson said 52 patients are ready for release when their home counties have space in local treatment programs. To prime that pump, the state recently made counties fully responsible for the cost of care at Anoka when it becomes medically unnecessary to keep them there.
“We can’t just open the door and say, ‘Go on back to your apartment now,’ ” Jesson said.
In Hennepin County, private agencies are opening two 16-bed intensive residential treatment units to provide that transition — both for patients in Anoka and those stuck at HCMC — and the hospital is trying to create a similar 10-bed facility of its own.
Hospital officials said they don’t want to eliminate the 48-hour rule — and just shift their burden back on the jails — but said it should account for the fact that some hospitalized patients are sicker than jail inmates and in greater need. State data show that 10 percent of the inmates transferred by rule to Anoka don’t need that level of mental health care.
Hennepin County Sheriff Rich Stanek was in Washington, D.C., Thursday, helping brief members of Congress about mental health issues and seeking additional funding for treatment beds in a state that has the 50th lowest rate of mental health beds for its population.
In an interview Friday, Stanek bristled at any changes that would help hospitals by weakening the 48-hour rule; he said the state should do more to support mentally ill patients coming from all locations.
“It shouldn’t be a competition between the sheriff and the jails and the hospitals.”