Monday, June 21, 2010

People who need mental health care in Georgia sometimes wait days for a bed

From The Atlanta Journal-Constitution. In the picture, the Odd Fellows Building on Auburn Avenue in downtown Atlanta is the new home of Grady Memorial Hospital's outpatient mental health clinic.

Richard P. was distraught. After arguing with his former wife, he checked into a motel, looped a belt around his neck and tried his best to take his own life.

The belt broke.

So Richard entered the labyrinth of Georgia’s mental health system. On June 5, hours after Richard’s suicide attempt, an emergency room doctor committed him to a state psychiatric hospital. He was, as a counselor said, “a suicidal, wanting-to-die patient.”

But no beds were available in the state hospital that day. Or the next day. Or the day after that. It wasn’t until June 8 — 82 hours after Richard’s commitment — that a crisis unit in Cobb County accepted him.

Richard’s experience, detailed in a document prepared for state officials, demonstrates how patients have been harmed since Georgia began paring back its state mental hospitals in favor of community-based services that often do not yet exist, an investigation by The Atlanta Journal-Constitution shows.

Hundreds of psychiatric patients have spent hours, days — as long as a week — in emergency rooms awaiting admission to state hospitals or other mental health facilities, according to health care executives, physicians and others familiar with the situation. Few patients receive psychiatric care in the emergency rooms. Some get no more than a chair to sit through the delay.

Just since April, more than 230 patients committed to Georgia psychiatric facilities — nearly one of every five — have been forced to wait 24 hours or more before being admitted. At least two waited in emergency rooms for seven days, state records reviewed by the AJC show, and three others spent more than six days in limbo. Many are psychotic or suicidal, a threat to themselves or others — a volatile group of people not getting the psychiatric care they need.

“They’re very high risk” and require “a very high level of attention,” said Dr. Robert Cox, president of the Georgia College of Emergency Physicians. “We stabilize them in the emergency department rather than the psychiatric hospital stabilizing them. That’s not optimal. ... It’s not our specialty.”

It is, nevertheless, expensive. Georgia hospitals say they spent $68.8 million last year treating uninsured psychiatric patients in emergency rooms — an increase of almost 50 percent since 2006. The additional costs, health care executives said, reflect longer waits for transfers to state hospitals.

Those waits coincide with Georgia’s efforts to negotiate a settlement with the U.S. Justice Department, which has alleged that conditions in the state hospitals violate patients’ civil rights. The federal investigation began in 2007 after the AJC reported that abuse and neglect had contributed to the deaths of more than 100 patients in five years.

As the negotiations continue, the state hospitals seem to have become especially cautious about accepting patients with acute psychotic conditions, said Matt Crouch, chief executive of Peachford Hospital, a private psychiatric facility in Dunwoody.

“It’s decreasing the size of the target on their backs,” Crouch said.

State officials disputed that characterization. They acknowledged, however, that state hospital admissions are down — by 28 percent just since last July. They attribute it to Georgia’s effort to shift from a mental health system dominated by a few regional in-patient institutions to a more diffuse one based on treating patients in their communities.

“As part of that change, there are going to be some hiccups along the way,” said Thomas Wilson, a spokesman for the state Department of Behavioral Health and Developmental Disabilities. “There are going to be times when we are at capacity.”

An ambulance took Richard P. to Emory Adventist Hospital in Smyrna. Like most of the 168 hospitals in Georgia, Emory Adventist does not operate a psychiatric ward. However, like about two dozen others, it pays Peachford to assess psychiatric patients in its emergency room and find appropriate places for their treatment.

On Richard’s first day at Emory Adventist, placement counselors from Peachford tried to transfer him to Northwest Georgia Regional Hospital in Rome, to Cobb County’s state-funded crisis stabilization center and to two similar facilities. Each was full.

The second day, the same facilities again declined to accept Richard, whose full name was deleted from documents obtained by the AJC. The state hospital said it wouldn’t admit him because he qualified for veterans’ benefits, according to a summary prepared for state officials, even though a Peachford counselor pointed out that veterans’ hospitals won’t accept psychiatric patients with conditions as acute as Richard’s.

On the third day, all four facilities said they had no bed for Richard. And the Peachford counselor and a state hospital employee again argued over Richard’s veterans’ benefits.

The fourth day brought no change, at first. But the placement counselor complained that other patients were admitted while Richard had been “passed over,” according to the summary. Richard finally got into the Cobb crisis unit.

Georgia law requires the state to provide or pay for hospital treatment for psychiatric patients who need it, said Crouch, the Peachford executive. Yet “this is a daily occurrence,” he said of delayed admissions. “Things are backing up all over.”

In April, state records show, the average wait time for admission was almost 14 hours. That number increased to 16.5 hours in May before falling slightly to about 15 hours in early June. Comparable statistics for other periods were not available.

The situation worsened over the long Memorial Day weekend.

That Friday, Peachford’s placement counselors learned that the state hospitals not only weren’t accepting patients, they would not even consider transfer requests until the following Tuesday. At 3:28 p.m. that Friday, Crouch e-mailed Frank Shelp, the state’s behavioral health commissioner.

“Are patients going to have to just ‘sit tight’ until Tuesday?” Crouch wrote. “Please call me if you have any suggestions as to how we can get these consumers served this weekend.”

Shelp answered the e-mail that Sunday night, asking for more information. Later, Crouch said, Shelp told him his staff had assured him the state facilities had enough beds to handle the long weekend’s demand, Crouch said.

Psychiatric patients, however, crowded into emergency rooms through the weekend.

At North Fulton Regional Hospital in Roswell, for instance, patient Elizabeth B. waited from Saturday to Tuesday — 68 hours — until Georgia Regional Hospital/Atlanta agreed to admit her, according to her case summary. But then the state hospital delayed transporting Elizabeth; she ended up spending 116 hours, or almost five full days, in the emergency room.

At Barrow Regional Medical Center in Winder, patient Patrick E. came to the emergency room that Friday. He stayed 72 hours. Then, “due to a lack of beds,” his case summary said, “Barrow ultimately chose to send the patient home without any treatment.”

A man holds himself in a tight hug as he rocks in a continuous motion, back and forth, back and forth.

A few feet away, a woman in a green recliner sleeps beneath a white cotton blanket, undisturbed by the television showing quarter-century-old reruns of “The Cosby Show.”

A few other people pace the length and width of this room, a temporary observation area on the 13th floor of Grady Memorial Hospital: the psychiatric ward.

Among Grady’s patients, psychosis is the third most-frequent diagnosis. But Grady is one of the few hospitals in metro Atlanta that has a psychiatric unit — 31 beds, plus space for 14 patients in this observation area. It’s not enough.

“There’s always people waiting for those beds,” said Sue Green, Grady’s chief operating officer and a former psychiatric nurse. “The need is huge and ever-growing.”

Patients may spend a day or two in the observation area — known in the hospital simply as “chairs” — before the medical staff has to decide whether to move them into hospital beds, try to transfer them to state hospitals or let them leave.

“There’s nowhere else for them to go,” Green said. “It’s not the ideal situation. But it’s the best we have to offer at this point.”

In theory, Grady can send patients to Georgia Regional/Atlanta for longer-term treatment. In reality, Grady keeps psychiatric patients two to three times longer, on average, than Georgia Regional, and the state hospital rarely accepts Grady’s patients, anyway.

“It’s our experience that it’s very hard to get a patient into Georgia Regional,” Green said. “They will tell you we aren’t asking. But at some point, you get tired of asking. We just keep on building services to take care of them here.”

Grady recently opened an outpatient mental health clinic on Auburn Avenue, a few blocks from the hospital campus. There, patients see psychiatrists and therapists and pick up prescriptions away from the sometimes chaotic atmosphere of the hospital.

Still, many psychiatric patients enter Grady through its emergency room — by ambulance, in police cars, on foot.

Regular patients, though, often bypass both the outpatient clinic and the emergency room, Green said. They hop on an elevator and ride directly to the 13th floor.

On June 13, University Hospital in Augusta posted an urgent message on a Web site called the Georgia Hospital Resource Report: “Psych saturation. We have no in-house beds available — holding in the [emergency department].”

The next day, the Medical College of Georgia, also in Augusta, posted its own warning: “We are on adult psych diversion until further notice.”

Such reports — under a heading that says, “ALERT! ALERT!!” — are common as emergency rooms deal with greater demand by psychiatric patients.

Most hospital emergency rooms are not set up for psychiatric care, said Cox, the president of the emergency physicians’ organization. They often need constant supervision, he said, and occupy nurses or security guards full time.

“We’re responsible for that patient during their entire stay,” even if they are only waiting to transfer to a psychiatric hospital, Cox said. But the patients, he said, rarely see psychiatrists during their time in an emergency room.

Wilson, the spokesman for the behavioral health agency, said what emergency rooms are experiencing amounts to “bumps in the road.”

“Over time,” he said, “that’s going to work itself out.”

The state wants to expand its network of 16 crisis units, Wilson said, as federal authorities push to eliminate or reduce the size of the state hospitals. Advocates for people with mental illness have urged that direction for years, Wilson said.

“The number of state hospital beds is not going to do anything but go down,” he said. “We just have to make sure we manage it in a way that we don’t have people falling through the cracks.”