January 2007 | Back to Table of Contents

Take A Number

Getting one of Minnesota's inpatient psychiatric beds is still a waiting game.

By Scott D. Smith

December 30, 2005, was a harrowing day for Roland Miles. His schizophrenic son, Stephen, 23, had tried to choke him and kicked over a television set in anger after his father stopped him from trying to remove his dental fillings with a fork.

A staffer at the Dakota County Crisis Line told Miles to get his son to a hospital. There may not be an available bed, he was told, but the hospital could at least hold Stephen for 72 hours and physically restrain him if needed. During the car ride from their home in Burnsville to Fairview Southdale Hospital in Edina, Stephen threatened to stab his father in the neck with a pencil if he kept talking. Roland Miles was scared.

Miles and Stephen’s mother, Carol, hoped the hospital would involuntarily commit their son so the young man could get the help he needed.

But that didn’t happen. Fairview Southdale’s psych beds were full, and the attending physician, an ER doctor, concluded there were no grounds to hold Stephen against his will. He referred Stephen for further evaluation at Fairview’s Behavioral Emergency Center in Minneapolis, which has a dedicated mental health staff that can hold and evaluate psychiatric patients.

Stephen’s parents reluctantly agreed to take him to the center, even though there was no guarantee those doctors would restrain him or have a bed for him. But Stephen Miles didn’t want treatment. Like many psychotic patients, he didn’t think he was sick. Miles had tricked Stephen to get him to Southdale, and now Stephen knew his parents were trying to commit him. “He’s certainly insane, but not stupid,” Miles says. Plus, Miles and his ex-wife were unsure if they could physically get their son to the hospital.

So they took Stephen to Miles’ home instead. Hours later, while Miles was outside shoveling his driveway, Stephen beheaded his stepmother, Maris Jo, with a knife.

Miles is still dismayed that the medical system failed his family. And he fears similar tragedies will continue to happen unless it changes. He would like to see enough psych beds and available resources so mental health professionals could proactively respond to patients like his son instead of pushing the problem of their care back on families. Although he has declined other offers to tell his story, he agreed to speak out now in hope that he might help fix a broken system.

“Hospitals have a medical responsibility to heal the sick,” he says, “and I don’t think turning away people who are sick is responsible.”

Still No Room
A year after Stephen Miles killed his stepmother, some improvements have been made. But fundamentally, there’s still a lack of options for mentally ill patients in the metro area, where the inpatient bed shortage is most acute. For example, on a Tuesday in late November, a young lady who was twirling in front of a television screen had been waiting about 60 hours in Hennepin County Medical Center’s (HCMC’s) Acute Psychiatric Services center, a specialized intake unit for patients in crisis, because none of the 613 private metro-area mental-health beds or any of the beds at the state-operated Anoka Regional Treatment Center were available.

And wait times continue to lengthen. The average time it takes HCMC to secure a bed for a patient either in-house or at another hospital was eight hours two years ago; it is 14 hours today.

The metro area’s psychiatric bed shortage is not a new or hidden problem. It has been widely reported in newspapers and media outlets for at least five years. In April, the Star Tribune published an article, “No Room Here,” that quoted psychiatrists as saying that more than 1,300 patients a year from across the state are moved by ambulance from their local hospitals to a facility that has an open bed. Children and adolescents needing inpatient care fare worse than adults. The number of pediatric psych beds declined from 132 to 114 between 1999 and 2005, according to the Minnesota Department of Health’s Health Economics Program.

Michael K. Popkin, M.D., chief of psychiatry at HCMC, sees the current bed shortage and resulting chaos as a product of the state’s closing its regional psychiatric hospitals. He calls Minnesota’s care for the mentally ill “a game of musical chairs.” “The state keeps taking away the chairs, and there is no place for the mentally ill to sit down,” he says. Between 2000 and 2004, the state reduced its psychiatric beds from 616 to 273, according to the Minnesota Department of Human Services.

Popkin is concerned that the state closed hospitals and cut beds for economic reasons and would like to see greater transparency in the state’s financing of mental health care.

State officials say the decision to close the hospitals was based on the widely held view that mentally ill patients should be treated in the community, where they can be close to family and lead better lives, rather than in the hospital.

Beyond Beds
Advances in medication and other treatments have made a shift to community-based treatment possible. As a result, Minnesota’s average daily census of adults in state-operated psychiatric hospitals declined from nearly 1,400 in 1980 to 275 in 2006, according to Minnesota Department of Human Services data. The state plans to close all but one of its regional treatment centers and replace some of those facilities in greater Minnesota with 16-bed hospitals designed for stays of up to 30 days. (The state will maintain its facilities for people who pose a risk to the public at St. Peter, Moose Lake, and Cambridge.)

The one regional center that will remain open, the Anoka Regional Treatment Center, which serves the metro area, has 200 beds. It also has as many as 50 people on a list waiting for a bed, and wait times average 25 days, according to Mike Tessneer, chief executive officer of state-operated services for the Minnesota Department of Human Services. Tessneer says about half of the patients on the waiting list receive care elsewhere and of those admitted, half don’t need the level of care provided at Anoka but have no other alternative.  

Sharon Autio, director of adult mental health for the Minnesota Department of Human Services, blames the bottleneck at Anoka on a lack of good discharge options. Autio says that as many as 30 percent of patients in the Anoka center could be discharged if a workable alternative such as placement in a supervised-living setting were available. “There are so many factors that the immediate answer is not just to add more beds,” she says.

Autio is not alone in her opinion. Others point to inadequate staffing or patient-flow problems for the delays in care. The solution, many say, is to build up outpatient services so patients can receive the appropriate level of treatment for their condition, with the goal of stabilizing and returning them to the community. This could be accomplished by sending patients to group homes, intensive day programs, adult foster care, and crisis transitional facilities such as the Hewitt Crisis Residence, a facility in St. Paul with 12 beds that can accommodate patients for a maximum of five days and four beds for 30-day stays, and transitional programs that provide patients with a place to live and the counseling and training they need to one day live on their own.

Advocates of such solutions say these services have always been in short supply but that the deficit has become more acute because of the reduction of inpatient options.

A Multifaceted Problem, Multiple Solutions In 2005, Minnesota had 16.8 mental health beds per 100,000 residents, which is slightly more than half as many as the national average of 28.2 beds per 100,000. Psychiatrists and other mental health experts say that’s created a problem for the state’s mentally ill population. But few agree on how to solve it. Here are a handful of proposals discussed by individuals interviewed for this story: • Add more Assertive Community Treatment teams in Hennepin County and in the east metro; • Increase staffing at the Anoka Regional Treatment Center so it can admit patients on the weekend; • Restaff a significant number of closed beds at the Anoka Regional Treatment Center in order to reopen them for patients; • Create an Internet-based system to track available inpatient beds; • Add more psychiatric evaluation centers similar to those at Hennepin County Medical Center and University of Minnesota Medical Center, Fairview, which serve as psychiatric emergency rooms; • Increase reimbursement particularly for outpatient care; • Create and fund a system (similar to the state’s trauma system) of hospitals with expertise in psychiatry; • Hire more psychiatrists to work as full-time psychiatric hospitalists; • Create a network of pharmacies that can dispense medications to mentally ill patients at all times regardless of those patients’ ability to pay.

State reductions aren’t the only reason for the acute-care crisis. It’s also clear that Minnesota’s nonprofit hospitals aren’t meeting the demand for psychiatric services. Only about 25 percent of Minnesota’s 136 hospitals offer psychiatric inpatient services. Mental health is not a profitable area of business hospitals want to take on, says Steven Sterner, M.D., an emergency physician at HCMC.

The sickest patients seem to be the least desirable. “What everybody wants to do is cherry pick, everybody knows that,” Sterner says. “So what happens is that the patients who are really hard to care for—and it’s especially true in mental health—end up being unacceptable to most programs.”

Low reimbursement levels make it difficult for private hospitals to offer psychiatric services. Other factors that add to the problem include a shortage of psychiatrists (particularly in rural areas) and an institutional discomfort with treating mental illness.

An Ounce of Prevention
A spate of solutions to the psychiatric bed shortage are being proposed from experts in all sectors. One idea is to keep patients healthy enough so that they don’t need hospitalization. The state has pinned its hopes for keeping patients out of the hospital on an interdisciplinary approach developed in Madison, Wisconsin, in the 1970s, known as Assertive Community Treatment.

Assertive Community Treatment uses teams of 10 to 12 professionals including a psychiatrist, nurses, social workers, vocational specialists, and others to provide comprehensive services to severely mentally ill patients, many of whom have a history of hospitalization. The concept is likened to a “hospital without walls” because of the intensity of services provided.

The medical literature indicates that such teams can reduce the use of inpatient services. Autio acknowledges, however, that the Twin Cities currently lacks enough teams to get the job done. Since 2005, Hennepin County has formed six teams but needs 10 more; the east metro counties have eight teams and could benefit from more as well, she says. The teams are funded by federal, state, and county dollars.

In greater Minnesota, the Department of Human Services has opened 16-bed community behavioral health hospitals in Alexandria, Annandale, Rochester, St. Peter, and Wadena. Five more are planned for Baxter, Bemidji, Fergus Falls, Cold Spring, and Willmar. With these centers, the Mankato Crisis Center, and Bridge House in Duluth, the state’s community-based acute-care bed capacity will increase to 182.

In addition, the state increased reimbursement for psychiatric services by 23.7 percent in 2006 for patients on state-funded programs, and it is spending $336,000 to develop a Web-based system to track and provide real-time information regarding the availability of psychiatric acute-care beds for children, adolescents, and adults.

Hospitals that already have psych programs are also stepping up to address the shortage of mental health beds and services. According to the Minnesota Hospital Association, metro-area hospitals have increased the number of their inpatient psych beds from 578 in 2000 to 613 in 2004. Hennepin County Medical Center, which sees about 12,000 mentally ill patients a year and admits about 2,000, is investing $15 million to add 20 more beds for a total of 100 and to renovate its psych wards and its acute psychiatric services unit.

The acute services unit, which has eight holding rooms and seven treatment areas, is heralded as a model for how emergency departments should manage mentally ill patients in crisis. Patients arrive either voluntarily or are committed involuntarily by the courts. A physician can request that the facility hold patients deemed a danger to themselves or others for 72 hours.

Joanne Hall, R.N., the unit’s clinical administrator, says it is a much better place for patients to wait for a bed than an emergency room. Patients are insulated from the noise of the ER, and they can take a shower, eat a meal, watch television, sleep, and even pace if they need to. In a standard emergency room, strapping a patient to a gurney—possibly for hours—is often the only way to hold them.

The University of Minnesota Medical Center, Fairview, which has the largest inpatient psychiatric capacity in the state with 165 beds, has hired additional psychiatrists and opened Fairview Behavioral Emergency Center (BEC), an acute-care unit similar to HCMC’s.

Improved assessment and ability to stabilize patients in the BEC has reduced unnecessary hospitalizations, says Kathy Knight, vice president of behavioral services for Fairview. In the past, 80 percent of patients seeking care in the emergency department were hospitalized compared with only 50 percent today.

Knight says about 14 percent of the hospital’s beds had been closed because of physician-staffing shortages. Since the hospital hired five in-house psychiatrists earlier this year, who serve as psychiatric hospitalists, those beds have been reopened. With the creation of the BEC and the hiring of additional physicians, Knight says the hospital didn’t have to turn away a patient because of a bed or physician shortage between July and December of 2006.

HealthPartners, the largest provider of mental health care in the east metro area, also has been working to improve access to emergency care. Mary Brainerd, CEO of HealthPartners, which owns Regions Hospital in St. Paul, has joined with 25 community and health care leaders, including St. Paul Mayor Chris Coleman, to create a system that could guarantee mentally ill individuals access to their medications 24/7. To increase inpatient capacity, in 2003 Regions opened Hovander House, a short-term residential facility. Hovander House is staffed by a psychiatrist 24 hours a day, and more than 150 patients receive care there every year.

Brainerd says Regions is planning to add 16 inpatient psych beds after 2009 as part of a $179 million expansion project that includes private rooms and additional capacity for cardiovascular, neuroscience, orthopedic, and trauma care. The additional psych beds will bring its total to 96. This type of investment can be challenging for hospitals because other service lines that often provide better financial returns are competing for the same space and resources.

Despite these steps forward, many people say the Twin Cities is still in the thick of a bed-shortage crisis that could result in another parent experiencing the consequences of a broken mental health care system.

When health care providers don’t take control of these difficult situations, Roland Miles says, they place a heavy burden on family members. “Society depends on [doctors] in these situations.” MM

Scott Smith is a staff writer for Minnesota Medicine.