It’s just really hard, because both mental health and substance abuse are not a nine to five, Monday through Friday problem.
Mental health caseload takes a toll on hospital ERs
This 10-part series, a collaborative effort of the newspapers of Rust Publishing, NWIA, examines the myriad issues surrounding the mental health care crisis in Iowa. Reporters and editors from the Spencer Daily Reporter, Storm Lake Pilot-Tribune and Dickinson County News have contributed to the report.
As community-based organizations and providers drop out of the already ragged patchwork of mental health and substance abuse treatment care, one room becomes the safety net for the safety net: the emergency room.
But as the elasticity of mental health care's plan B of local hospitals appears to be stretched to its limits, providers across Iowa are wondering whether more help is on the way.
"There's definitely more (patients), and it's more all the time," said Sarah Naberhaus, director of Buena Vista Regional Medical Center's emergency room and ambulance. "The severity seems to be increasing."
The 14-year veteran registered nurse at Storm Lake's hospital also notes that the severity of symptoms is growing more intense, and the problem is becoming particularly acute with children and adolescents.
"A few weeks ago we had someone who was catatonic," she said of an illuminating moment when their staff realized the increase in symptom severity was part of a trend.
Part of the increase in the number of children, she says, is because professionals are getting better at diagnosing issues early. Other spikes, she believes, are indicative of the deficiencies in our mental health care system.
MORE PATIENTS COMING FORWARD
"The issue becomes more and more prevalent as people seek help versus internalizing it," said Brandon Rohrig, Lakes Regional Healthcare's Director of Public Health. "It's a need that's going to continue to be a very high need, and it doesn't come at a convenient time."
But he's glad people are becoming more comfortable in seeking help with issues, instead of trying to "toughen up."
In Storm Lake, where dozens of languages are spoken, a unique stigma is embedded in other cultures, creating a new dimension of difficulty around communication with language interpreter lines and patients.
In Pohnpeian, for example, there is no word for "suicide," which means nurses have to get creative with their routine questions when communicating with Micronesians.
Compass Pointe provided 24/7 providers available on call to evaluate those in need of treatment to determine the proper course of action.
Now, hospitals, which used to work with the organization, are forced with the choice of setting up an outpatient appointment — wherever they can find one in a dwindling network of area providers — or keeping them until someone can evaluate them, which can take hours. The gap between obvious outpatient needs and inpatient needs might be larger than you expect.
"It's just really hard, because both mental health and substance abuse are not a nine to five, Monday through Friday problem," said Naberhaus.
Even in hospitals with a well-staffed ER, the surges can pose challenges for infrastructure as valuable bed space and nursing resources are occupied more and more for mental health issues that would sometimes be better handled in outpatient settings.
But even in outpatient settings, appointments with psychiatrists can be difficult to come by, Naberhaus said, reinforcing a vicious cycle with the ER.
Spirit Lake's facility sees about 30 to 40 ER patients per month for behavioral health, of whom about 10 need inpatient services, according to Director of Emergency Services Chris Ingraham. That inpatient admission rate is higher than any other type of illness (such as cardiac arrest, stroke and respiratory issues) Spirit Lake's ER handles.
Lakes Regional Healthcare and Buena Vista Regional Medical Center reported an increased use of telemedicine out of various outlets in Sioux Falls and Fort Dodge — a godsend for the increased need for behavioral health counseling and services in rural hospitals hit hardest by the loss of community-based providers.
Ingraham says he would like to see more use of this to be able to conduct more appropriate triage faster for patients, rather than sending them across the state.
Suicidal patients require direct one-on-one supervision at all times. Those needing inpatient behavioral health care can stay in the ER for 36-40 hours or more as providers strive to find a placement somewhere in the state.
"This is low compared to other facilities where patients may stay in the (emergency department) a week or longer as care is sought," said Spencer Hospital's Emergency Department Director, Laura Manwarren.
FINDING A BED
Lengthy waits for inpatient psych beds can absolutely cripple places like Lakes Regional Healthcare, whose ER typically staffs two nurses at a time.
Placements start by calling around for the closest facilities with beds. Buena Vista Regional Medical Center starts with Cherokee Mental Health Institute and St. Anthony's in Carroll.
"Cherokee (MHI) has far less beds," than in the past, Naberhaus noted, along with Independence's state facility. "Very few long-term beds exist. When I say inpatient, there are few that will stay for 30 days."
In reality, she said most are seen, evaluated and released from inpatient care within a week. This can be problematic, as psychotropic drugs do not work nearly that quickly.
"A lot of times when we see them, they're so sick and out of control," she said. "We find out they were there for three days and we go, 'What?!'"
"It takes several weeks for medications to work properly," said Ingraham. "They need to be seen more routinely and frequently."
Nonetheless, they leave that decision to the psychiatric experts, no doubt under logistical pressures in their own facilities.
Bed placements are notoriously difficult to find in Iowa. CareMatch, a statewide system which shows available beds, is touted as a key part of the solution to that problem by the state as it moves its emphasis in addressing mental health care from state facilities in Cherokee and Independence to private, inpatient facilities.
Asked to respond to the state's lack of beds as experienced by providers, Matt Highland, Public Information Officer for the Iowa Department of Human Services, cited rankings that show Iowa at number 29 in the country for number of inpatient psych beds per capita, at 20.8 per 100,000. The chart "shows Iowa near the middle, not the bottom," Highland reassured.
Health policy experts broadly recommend 40 to 60 inpatient beds per 100,000.
Naberhaus called the state's reassuring attitude toward Iowa’s mental health care infrastructure "frightening."
A 2017 report from the Treatment Advocacy Center, cited by the National Association on Mental Illness Iowa, gave Iowa a D- grade in part due to its mental health bed shortage. Twelve states were ranked with a D- or F in that report. Headlines made rounds in 2016 citing Iowa as absolutely last for state psychiatric beds.
The situation has turned many nurses into matchmakers in addition to care providers.
"They're not very good about keeping it up to date," Naberhaus said of the CareMatch system. Buena Vista Regional Medical Center often just calls around instead for more updated findings.
It would be nice if they kept it updated daily or hourly, she said, but even then it "doesn't tell the whole story of whether they can take a patient or not."
"Many times the beds are not appropriate to meet the needs of the patients," said Debra Broderson, Behavioral Health Services Director at Spencer Hospital.
Spencer and Spirit Lake sources said most facilities often lack beds for children and adolescents, psychiatric intensive care, long-term care or violent patients. Spencer Hospital often admits patients from all over the state to its 15-bed behavioral health unit due to the limited inpatient beds in the region.
Of those patients who do show up at Spencer Hospital's ER, about half require hospital admission. Manwarren told the Pilot-Tribune the majority of patients there for behavioral health concerns would not come in if there were greater access to routine outpatient care.
"Sometimes it feels like I work with psych on a daily basis," Naberhaus said, even though she isn’t a psych nurse — a reflection of the new reality in nursing with the mental health care crisis.
Is our infrastructure for mental health adequate?
"No," she replied without reservation.
"Many people and organizations are working diligently to enhance behavioral services in our community and region," said Bill Bumgarner, CEO of Spencer Hospital, noting substantial progress over the past decade. "But much work remains."
Bumgarner notes hindrances in efforts are primarily from insufficient reimbursement and a shortage of behavioral health professionals.
- The people who care (06/04/19)
- New programs, static funding strain Iowa's mental health system (06/04/19)
- At the forefront of mental health (06/04/19)
- Responding to the mental health crisis in NW Iowa: Beating the stigma (05/29/19)
- MHI Cherokee: a portal between the past and future of mental health care (06/11/19)
- Law enforcement challenged with limited resources (06/18/19)
- 'The biggest mental health facility in the state is the county jail' (06/18/19)
- The two Jeffs -- Part I: Criminal cases reveal hidden hurt (06/25/19)
- The two Jeffs -- Part II: Guilty plea leads to tragic end (06/25/19)
The evaluation experience
The process starts with some questions. Thoughts of self-harm are at the forefront, following by other questions to determine symptoms and appropriate courses of action.
If a patient says they're suicidal, a nurse takes their vitals and asks them if they have made a plan to complete suicide. They ask the patient how long they have been thinking about it.
The nurse will attempt to find his or her stress points to determine if they're going through a manic phase or if any life situations may be contributing to suicidal behavior.
If a patient is unreceptive to answering questions, an ER physician can examine them to make appropriate deductions for care.
Every patient that comes in for behavioral health gets blood work done to rule out other medical causes of behavioral issues.
If they are willing to answer questions, a behavioral health counselor gets involved to determine patient admission and patient needs. Those at a substantial risk for self-harm are placed on 24-hour watch.
Those who don’t need inpatient admission might just need medication adjustments or the right outpatient appointment.
Often, the latter case is seen when patients don't know where else to go or have drops in providers or gaps in care.
"They go to what’s familiar instead of seeking out other services," said Brandon Rohrig, Director of Public Health at Lakes Regional Healthcare. Two of the three area hospitals surveyed noted the biggest need in mental health care now is children's mental health and one-on-one counseling.
Past history with mental health is ascertained, as well as regularity of medications, or "self medicating," which often exacerbates the issue, according to nurses.
"It makes it much worse," said Sarah Naberhaus, the emergency room director at Buena Vista Regional Medical Center. "With those things readily available, there’s a lot more choice for them to try to self-medicate."
And self-medication becomes a more attractive option as the professional solutions suffer a death by many cuts.
"With adults, there's less community services," Naberhaus said. "The funding gets cut all the time. That’s one of the things that there’s really a need for with these patients."
Lakes Regional Medical Center’s ER director, Chris Ingraham, also acknowledged a local role played by a national epidemic with narcotics.
"Compass Pointe's closure hasn’t affected the ER as much as inpatient," he said. "When we’ve had those folks admitted upstairs for detoxing, we’d refer to Compass Pointe to have them come in and see the patient."
Without Compass Pointe, they refer to Seasons and Jackson Recovery Center, which are further away and less timely, affecting patient discharge timing and continuity of care with follow-ups.