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Under the Microscope
Thu May 17, 2012
Mid-Missouri hospitals work to provide psychiatric care
The mental health care system is faced with diminishing resources, making it harder for people with psychiatric illnesses to find help. From police officers to school counselors, people outside of the system are working to fill the gaps. Project 573’s Angela Case explains how community hospitals are dealing with the problem, and takes you inside two units that provide this much-needed care.
Nurses prepare medication for patients at Callaway Community Hospital in Fulton. Here, the number of people visiting the ER for psychiatric care is increasing. This is a problem for the small hospital, which has few resources to treat people with mental illness. Chief Nursing Officer Chuck Baker says the hospital has one social worker on call, but no staff members trained in psychiatric care.
“All we have is the ER physicians and the nurses, which have some generalized training in psychiatry just from school, but they’re not formalized.”
Hospitals throughout mid-Missouri face the same challenges. For people needing psychiatric care to treat mental illnesses like depression and bipolar disorder, ERs like Callaway’s aren’t the best places to go. Most have no mental health professionals on staff and few stabilization and treatment resources. But nationwide, the number of people who visit the ER for psychiatric care is increasing. The Federal Agency for Healthcare Research and Quality reports nationally, one in eight ER visits in 2007 was related to substance abuse or mental illness. That’s twice the number from seven years earlier. These increasing numbers bring a new set of challenges to small community hospitals that don’t have the resources to treat people with mental illness.
The ER staff at Callaway has the medication and basic skills to stabilize psychiatric patients. But to receive the acute care they really need, patients have to be transferred elsewhere. Usually this means a trip by ambulance to Columbia, Jefferson City, or even St. Louis. While they’re waiting for a bed to open up at one of these acute care facilities, patients are either held in the Callaway ER or admitted to the main medical hospital.
“Sometimes we have to admit those patients here basically as medical patients, even though we don’t have the services to provide their psychiatric needs,” said Baker.
Finding a bed can be a long and difficult process for the Callaway ER staff. But at another mid-Missouri hospital, the process is a little simpler. The ER at University Hospital in Columbia contains a dedicated assessment unit staffed by RNs and psychiatric aides from the affiliated Missouri Psychiatric Center. This means patients can receive physical and psychiatric care in the same place. Emergency services manager Brenda Jensen explains how the two units work together:
“First they’re screened -- we call it a medical screen -- to make sure there are no prevailing medical issues, and they they’re taken to the psychiatric portion of the ER.”
Once patients are medically stable, staff transfers them to the psychiatric assessment unit. Medical director John Lauriello says assessment unit staffers interview patients to identify the problems they are facing.
“Sometimes it’ll be as simple as I’m out of my medications and can you help me get to the bridge to the you know the next day. Or it can be as complicated as really severe voices or paranoia or suicidality,” Lauriello said.
Many of these patients need treatment for both physical and psychiatric emergencies. For example, a patient overdosing on pills due to complications from a mental illness would need both types of care. ER doctor John Montgomery explains how the staff cares for these patients:
“If it’s an alcohol issue, we make sure that they’re not having troubles or problems from the alcohol, that they’re sober, before they ever go to the psychiatric hospital.”
Many ER visitors are already being treated for their mental illness. They come to the ER when facing an immediate crisis -- like a mental health version of a heart attack. But Lauriello says that some use the hospital as their first point of contact with the mental healthcare system.
“You’re going to get people who have been for economic reasons can’t access care, but you also have people who refuse care.”
University Hospital declined to give stats on where people go after they leave the assessment unit, but according to Lauriello, some are admitted to the center’s inpatient hospital. There, they receive a few days of acute care before returning home. The inpatient hospital has 57 beds serving children, adolescents, and adults, but there is no unit specifically for geriatric care. That’s why psychiatric patients over the age of 50 are often transferred 40 miles to Moberly Regional Medical Center. The hospital has a 30-bed unit just for seniors -- the only one of its kind in mid-Missouri.
Candace Hawkes is a licensed clinical social worker and the director of the senior mental health unit. Hawkes rarely stops moving. She and her staff are responsible for coordinating transfers and providing care for patients from 44 counties across the state. Most stay for seven to ten days while mental health professionals provide therapy and reevaluate their medications. About half of the unit’s patients have dementia.
Others have psychiatric illnesses such as schizophrenia, bipolar disorder, and depression. In the unit, they receive care from more than 40 staff members, including recreational therapists, a medical doctor, and a psychiatrist. The unit is different from a regular psychiatric care unit because the staff has a better understanding of what medications and therapies work best for seniors, Hawkes says. And as she is quick to point out, the unit is nothing like a nursing home. The stays are shorter and there’s more emphasis on mental health care. But despite the carpeted floors and four recreation are as, it’s still a psychiatric facility. Everything from the door handles to the shower railings is specially designed for patient safety, and every room has a panic button for hospital staff to use in emergencies.
Hawkes says there’s a single-patient room equipped with a bed and nothing else, commonly known as a seclusion room. In many places, patients are put there to calm down. But Hawkes has never used the room, and doesn’t plan to.
“If this is your mom or dad, are you going to want them in the seclusion room?" said Hawkes. "I wouldn’t want my mother in a seclusion room.”
Hawkes and her staff specialize in seniors, but they often end up caring for younger people as well. When a person with a psychiatric emergency visits Moberly’s ER, people from the senior mental health unit are called in to help provide treatment. So psychiatric patients who visit Moberly’s ER are better off than they would be at many other mid-Missouri hospitals . But it’s still not ideal, because Hawkes and her staff are busy enough already.
This story was produced by Project 573, a multimedia reporting project on mental health care in mid-Missouri. For more on this story, and to see other stories about people working to fill the gaps in mental health care, visit project573.com.