Rural North Dakota hospitals called on to manage mental health crises. Can they handle it?
A consultant's report to close behavioral service gaps in North Dakota recommends that rural hospitals be able to assess, stabilize and transfer unstable psychiatric patients. But hospital representatives say they face significant challenges.
BISMARCK — North Dakota’s plan for closing gaps in psychiatric care relies partly on ensuring rural hospitals can take in patients suffering from a mental health crisis so they can be stabilized and transferred for treatment.
The lack of behavioral health professionals and chronic staffing shortages plaguing rural hospitals, however, will make the state's plan that much more difficult.
There are other problems as well, including providing hospital rooms that are designed to safely house psychiatric patients, who can present a risk to themselves or others when unstable.
The “safe” rooms require safe ligatures, appliances and even a certain kind of light fixtures, Erik Christenson, chief executive officer of Heart of America Medical Center in Rugby said.
“They are not cheap to install,” he told state health and human services officials. “All of that costs money.”
“Staffing is absolutely an issue at this point,” Christenson added, a point made by others.
Christenson was among hospital representatives who recently provided feedback to a consultant’s recommendations for improving behavioral health services across the state, including a modern, new State Hospital in Jamestown.
The input will be presented to an interim legislative committee that is studying the states’ mental health system and is expected to make recommendations in the upcoming session, which convenes in January.
North Dakota’s 37 critical access hospitals, which serve rural communities, would benefit from having a defined set of procedures for dealing with mental health crisis cases, Christenson said. “It should be much more uniform, I think, the process,” he said.
Shari Saxerud, care coordinator at CommonSpirit in Lisbon, said it takes hours on the phone to find a psychiatric hospital bed for a patient, a comment echoed by many providers and law-enforcement officials around the state.
“It is very hard to find a bed for adults and pediatrics,” she said. Then, even when the patient has insurance, sometimes the bed is unaffordable, Saxerud added.
Transporting patients to a medical center with an available psychiatric bed is also a problem, she said. Law-enforcement officials commonly are called upon to transport patients in marked squad cars — a practice that inaccurately implies the patient with mental illness is a criminal, mental health advocates have complained.
Ensuring one-on-one care for unstable psychiatric patients is difficult for critical access hospitals, which lack specialty staff and whose staff members are stretched thin, said Mike Delfs, chief executive officer of Jamestown Regional Medical Center.
“I think that’s a huge challenge,” he said, adding that rural hospitals must at the same time care for their medical patients.
Minnesota experimented with so-called “micro hospitals” to treat psychiatric patients in community hospitals, but the effort quickly proved unworkable, largely because of staffing problems, Delfs said.
Insurance reimbursement also poses a significant obstacle, said Todd Forkel, chief executive officer of Altru Health in Grand Forks.
In partnership with UHS, the company that owns Prairie St. John’s in Fargo, Altru has been trying to expand its psychiatric bed capacity from 16 to 48 beds, with additional beds later.
But that effort has run into a significant barrier because the partners have been unable to obtain a Medicaid waiver allowing expansion beyond 16 beds — which means the added beds would be ineligible for Medicaid payments, Forkel said.
Forkel pleaded with state officials to help eliminate regulatory and financial barriers, but applauded the state’s effort to expand services and close service gaps.
“This is an issue that’s only growing,” Forkel said. “We’re looking at what we can do to meet this important need.”
Rachel Sem, director of nursing at Sakakawea Medical Center in Hazen, compared the need for specialized psychiatric care to the need for specialty care to handle strokes and other medical emergencies — patients that rural hospitals send to urban medical centers.
“They still need those specialty services,” Sem said, adding that telehealth can be helpful. “Mental health is no different. It’s still a specialty. They still need those specialty services.”
A crisis center serving as a “one stop shop” could help rural hospitals handle mental health emergency cases, including assistance in finding a transfer bed for the patient, Sem said.
Rural communities in southwestern North Dakota don’t always have the support services needed to keep mental health patients stable, said Karen Goyne of Southwestern District Health Unit in Dickinson.
As a result, they continue to present as crisis cases in emergency rooms, where staff often give first priority to patients with medical emergencies, such as heart attacks or trauma.
“Sometimes mental health and substance use issues get kind of put on the back burner,” Goyne said. “That’s nothing against anybody, that’s what happens in the ER.”
Actually, emergency rooms are ill-equipped to handle mental health crises, said Lisa Wilson, director of behavioral health at CHI St. Alexius in Bismarck.
“Behavioral health patients do not belong in an ER,” she said.