Mental Health Services Under Increased Pressure

Sept. 28--Gregory's teenager was diagnosed with bipolar disorder six years ago.

In those six years, the family has made at least a dozen trips to hospital emergency departments. The teen's first trip to the emergency department was because of an overdose. The subsequent trips were during times of heightened crisis when Gregory's teenager would go from being a big-hearted, kind child to destroying furniture and threatening self-harm or to harm Gregory and his wife.

"We know it isn't the appropriate place to get care, but where else do we go?" Gregory said. "Jail is also not the appropriate place, but those are the only two places families have."

Gregory and his family live in Vancouver. The Columbian is not using his real name, at his request, to protect his family's privacy as his teenager continues to seek mental health services in the community.

Gregory's frustration is shared not only by other families, but also health care providers, emergency department staff and mental health service providers.

All acknowledge the mental health care system in Clark County and across the state has gaping holes. The service needs reach across the spectrum of mental health care: crisis services that give families an option other than emergency rooms or law enforcement intervention; inpatient beds that provide intensive treatment, counseling and medication management; qualified counselors and prescribers to provide treatment; and outpatient services to prevent more crisis situations.

In some ways, those voids have been compounded, local providers say, by this year's Medicaid expansion, which added tens of thousands of adults to the health program for low-income people. That expansion also meant a dramatic increase in the number of people eligible for state-funded mental health services.

Services stretched

Gregory's family is insured through an employer-provided plan that manages his teen's care. But those who receive coverage through the state's Medicaid program may have their services coordinated by the Vancouver-based Southwest Washington Behavioral Health Regional Support Network.

The regional network, which covers Clark, Cowlitz and Skamania counties, administers mental health care for Medicaid patients with higher-level diagnoses and needs. People must meet a state-established threshold, called Access to Care, in order to be eligible for network services. Southwest Washington Behavioral Health contracts with local mental health providers -- such as Lifeline Connections, Columbia River Mental Health and Community Services Northwest -- to provide services to those who meet Access to Care requirements.

People who have lower-level needs and don't meet the threshold receive their mental health treatment through their health plan or primary care providers.

Prior to the Jan. 1 Medicaid expansion, the regional support network had about 96,000 people who qualified for services in the three counties. In Clark County, nearly 70,000 people were eligible, said Marc Bollinger, the network's chief clinical officer.

The support network now has about 131,000 eligible people in the region, about 99,000 of whom live in Clark County, Bollinger said. The network is providing services to 7,000 to 8,000 people each month, he said.

"It's a significant increase in the number of eligibles," Bollinger said.

The support network's contracts with local service providers require those organizations to increase their capacity to meet the demand, Bollinger said.

That, he said, has been a challenge for a few reasons. The biggest factor: the overnight increase of 35,000 newly eligible patients. Add to that the time it takes to hire and get the proper credentials for new staff and the nationwide shortage of certain mental health care providers -- such as masters-level counselors and prescribers -- and local service providers are facing significant obstacles.

Still, Bollinger said, they've been able to adapt without sacrificing the quality of care provided.

The network expects providers to schedule patients for an initial appointment within 10 days of referral. Prior to Medicaid expansion, that goal was met 80 percent of the time. In January, that number dropped to about 60 percent, Bollinger said.

Now, providers are getting patients in for an initial appointment within 10 days about 86 percent of the time, he said.

"They've made significant strides even with all of the challenges," Bollinger said.

At Community Services Northwest, overcoming the challenges meant hiring more than a dozen new full-time employees and doubling the number of intake appointments the nonprofit offers each week, said Executive Director Bunk Moren.

"In February, it went off the charts," Moren said. "We were booked out four or five weeks for a mental health assessment."

Community Services Northwest had for the past six years offered 25 to 30 intake appointments a week. To accommodate the increase in eligible patients, they now offer 50 to 60 appointments each week, Moren said.

Community Services Northwest provides outpatient mental health services to adults. Since last year, the nonprofit's caseload has grown from roughly 700 people to more than 1,000, Moren said.

"Our numbers are still going up," he said. "It's over a thousand and growing."

Access issues

While local mental health service organizations are working hard to provide support for network patients, Dr. Jeremy Chrisman, medical director for primary care at The Vancouver Clinic, is seeing another segment of the population struggle to find services.

Those who need mental health support, just not to the higher levels of those who qualify for regional support network services, have the hardest time accessing care, Chrisman said.

"It's always been so bad that I'm not sure we would notice if it got worse," Chrisman said.

Primary care providers at The Vancouver Clinic typically treat diagnoses such as depression, anxiety or attention deficit hyperactivity disorder, and some may also be comfortable treating bipolar disorder, Chrisman said. They'll also manage medications prescribed by mental health providers. But if the patient needs care that extends beyond what the provider can offer, it's difficult to get that help, he said.

"When that gets tacked onto what a primary care provider has to take care of, it's only superficially taken care of," Chrisman said.

The Vancouver Clinic now has a pilot project in place to try to improve mental health care for its patients. A psychiatric nurse practitioner has been embedded in one of the clinic's primary care groups to provide additional treatment, prescribe medications and offer follow-up care.

"It seems fairly successful, and we're likely to roll that out to additional primary care quads," Chrisman said.

But that's not the only area of need, Chrisman said.

"The gaping hole in our community is inpatient psychiatric beds," he said.

Inpatient treatment needs

Gregory's teenager has been admitted to acute inpatient care facilities about eight times, with each stay ranging between two and nine days. On more than one occasion, he's been told there weren't any beds available.

"That's as defeating of a moment as you can imagine," he said.

Clark County has a limited number of inpatient treatment beds. PeaceHealth Southwest Medical Center has a 12-bed adult inpatient unit at its Memorial Campus on Main Street. Telecare, an Alameda, Calif.-based company, operates a 12-bed inpatient unit at the Center for Community Health. Options for children and teens are even more limited.

When local inpatient beds aren't available, case managers and family members have to cast a wider net and look for beds in other communities in Oregon and Washington.

On one occasion, Gregory's teenager spent a couple days in a pediatric hospital ward waiting for an inpatient treatment bed to open up out of town. There was nothing available locally.

Turning to emergency departments

On Aug. 7, the Washington Supreme Court banned "psychiatric boarding," the practice of hospital emergency departments involuntarily holding a mentally ill person beyond the initial assessment period until an inpatient bed becomes available. Hospitals have until Dec. 26 to end the practice.

Gov. Jay Inslee allocated $30 million to help identify more therapeutic beds for those patients but that money isn't expected to fully solve the problem, especially given the number of people who seek care through emergency departments.

PeaceHealth Southwest Medical Center sees an average of 20 patients per day for behavioral health services. People who come in are often suicidal or experiencing psychosis related to mental illness or substance abuse, said Randy Querin, hospital spokesman.

About 15 percent of the patients who go to the hospital's emergency room require hospitalization. Some are admitted to the hospital's inpatient unit, while many others are transferred elsewhere, Querin said.

At Legacy Salmon Creek Medical Center, the number of people seeking behavioral health services in the emergency department has grown significantly in the last seven years, said Brian Willoughby, hospital spokesman.

During the 2008-09 fiscal year, the hospital emergency department averaged 3.5 behavioral health patients per day. By the 2013-14 fiscal year, that average had steadily climbed to nine people per day. From April through July of this year, emergency room staff saw an average of 11.6 patients with behavioral health needs, Willoughby said.

It's difficult to point to one reason for the increase, said Sherri Wood, Legacy Salmon Creek emergency department nurse manager. Dwindling resources for outpatient services may mean people are in crisis more often, she said. But it also may be simply because the emergency room is an open door, Wood said.

When a person in crisis goes to a hospital emergency department, they're first seen by a nurse and physician who will work to stabilize the patient, Wood said. The patient is then evaluated by a social worker to determine what type of services the patient may need.

If the patient needs inpatient treatment, the social worker then goes to work searching for available beds. Legacy Salmon Creek does not have an inpatient unit.

"It could be a full-time job, 24/7, 365, to find beds," said Denise Fall, Legacy Salmon Creek nurse executive. "It is so hard to find placement. Everybody is full. Everybody is maxed out."

While emergency department staff, mental health providers and even family members agree that an emergency room isn't the best place for a person to receive mental health treatment, they all acknowledge better options aren't often available.

For Gregory, the emergency room meant keeping his teenager safe when other intervention methods failed to prevent crises.

"At any time, we were dealing with the best possible option of not many options," Gregory said.

Copyright 2014 - The Columbian, Vancouver, Wash.