As psychiatric services decline, mentally ill patients are filling Montana's ERs

July 7, 2023
Original story by the Helena Independent Record can be found here.

By Emily Schabacker

Hospitals across the country are stretched beyond capacity caring for more patients with mental illness than ever before. The ongoing closure of crisis services has left many people without access to therapeutic support, making emergency departments (ED) their first point of contact during a mental health crisis.

EDs are designed to treat physical traumas and are ill-equipped to provide regular care for people with mental illnesses. The resulting overflow of patients creates a potentially dangerous environment for both patients and staff.

Intermediate services like group homes, crisis beds and stabilization units can provide a therapeutic place for a patient to stabilize while under observation. Psychiatric services like these have come and gone over the years, but recently the closure of beds has escalated as the health care industry goes through its largest financial upheaval in modern history.

Montana, like many rural states, has long lacked a robust mental health system. 

“In Montana there’s outpatient care or inpatient care. There’s little in-between,” said Dr. Lisa Ponfick, president of the Montana Psychiatric Association and a practicing psychiatrist at Shodair Children’s Hospital in Helena.

With nowhere else to go, severely mentally ill people are dropped into understaffed emergency departments where it’s difficult to access psychiatric care or have adequate supervision. Long wait times under fluorescent lights and a cacophony of sounds can exacerbate symptoms, putting patient and employee safety at risk. Last year, for example, a woman seeking treatment for suicidal ideation fired a gun inside Billings Clinic’s ED while she waited for treatment. Police officers on the scene eventually responded with gunfire. 

Despite the risks, the practice of holding mentally ill patients in the ED is so common it has a name — ED boarding.

Prolonged boarding of psychiatric patients in the ED often results in poor outcomes and goes against best practices established by the American Psychiatric Association.

APA representatives, however, are empathetic, acknowledging that right now there is no other choice for those who could be a danger to themselves or others.

“We constantly run a waitlist that’s greater than the number of beds we have,” Ponfick said. “And it puts a strain on the medical system when they’re put in a medical bed.”

Recently, the strain has been so great that Ponfick has noticed that before a patient is admitted to the hospital, the severity of the mental illness must be extremely high — much higher than before.

She recently had one young patient go to the ED tell staff he planned to follow through with suicide as soon as he figured out how. He was discharged just a few hours later.

Ponfick said staff considered him low risk because he hadn’t yet formulated a detailed plan, which is a high-risk indicator of suicide.

Services dwindle

It’s estimated that the country is short up to 30,000 psychiatrists — medical doctors who can prescribe medications for mental illness management. The shortage is the result of underfunding, according to industry experts. Medicaid reimbursement, set by state governments, has failed to pay at a rate that covers the cost of delivering care. Private insurers are also guilty of short-changing providers.

The battle with reimbursement keeps provider wages low compared to other specialties, and it makes it difficult to keep community services up and running.

The challenges are compounded in Montana where geographical expanse keeps frontier communities fairly isolated, and where a long history of mental health provider shortages contributes to the state’s high suicide rate.

It’s not that Montana can’t recruit psychiatrists — Ponfick pointed to a handful of new providers around the state — but the significant staffing challenges at Billings Clinic have created a vacuum in the eastern part of Montana.

Due to limited staffing, the Psychiatric Stabilization Unit (PSU) at Billings Clinic was closed in December 2022, causing a significant reduction to the services offered at the regional hospital. Clinic leadership did not publicly acknowledge the closure until prompted to do so by the news media last month.

For four years prior to the closure, the PSU served as the only short-term, therapeutic treatment option for those in crisis. St. Vincent Healthcare does not provide any emergency psychiatric services, meaning all mentally ill patients in crisis are directed to the Billings Clinic ED.

When the PSU was operating, patients were held for up to 24 hours in a therapeutic environment where they regained some equilibrium and were connected to community services without being hospitalized. This created a relief valve for local hospitals and the community by keeping inpatient beds open and helping to manage mental illness in Eastern Montana.

However, it’s not uncommon for psychiatric services to be the first to go in times of financial hardship, said Dr. Robert Trestman, chair of the American Psychiatric Association's council on health care systems and financing. 

“If there’s one area hospitals cannot make money, it’s in psychiatric services,” Trestman said.

Behavioral health hospitals are closing around the country, with at least two closures occurring in Washington State in just the last two months.

Without these services, emergency department workers become responsible for stabilizing patients.

Staffing shortages

Over the last five years, the number of patients seeking behavioral health or psychiatric services at Billings Clinic has increased 20%, according to Zach Benoit, community relations manager at the Clinic. Annually, the hospital averages about 22,700 patient encounters across all mental health services.

These patients arrive in various levels of distress, and depending on the acuity of the patient's condition, it's required that at least one staff member stay with the patient for the entirety of their ED visit.

Patients may be placed on one-to-one staffing if they’re engaging in self-harm or have attempted suicide during hospitalization, according to Billings Clinic policy and procedure guidelines. Those who arrive under the influence of drugs or alcohol often have to wait until they sober up before meeting with a psychiatrist.

But staffing shortages at Billings Clinic have prevented employees from maintaining the one-to-one standard, according to one Billings Clinic worker who asked to remain unnamed.

“We don’t have the ability to pull a staff member away, especially when we’re short-handed," the employee said. "We are too vastly under-staffed to operate and take care of (the increase in psych patients) safely and appropriately.”

At one point this year, 17 psychiatric patients were being held in Billings Clinic’s ED despite only having a six-room pod designated for this patient population, the employee said. 

“There were people just in the hall and everywhere during that time … There were multiple patients with homicidal ideation coming out in front of the nurse’s station and plotting how they were going to harm staff,” the employee said in a May interview. “It’s getting to the point that we’re consistently holding 10-plus psych patients in the ER.”

Last October, a patient seeking care for suicidal ideation snuck a gun into the ED, where she fired the weapon once, injuring herself. When police arrived, she allegedly ignored commands to put down the gun and was shot by police officers.

The patient survived, but the incident is indicative of the dangers that can arise while holding patients in the ED.

The Clinic utilizes an open floor plan for psych patients being held in the ED as a therapeutic tool that allows them to maintain some autonomy. But without adequate staffing a dangerous situation can escalate quickly.

“Where that gets very frightening is if something happens with the patient where I have to disengage from however many I’m watching, I am still culpable if one of those other patients chooses that moment to do something,” the Billings Clinic employee said.

The Clinic uses a mix of in-house psychiatrists and telehealth providers to treat mental illness in the ED. Through a contract with a company called AmWell, patient evaluations can be performed remotely by a psychiatrist anywhere in the country.

While having the additional resource is helpful, it can take hours before a request for a consultation is even acknowledged, according to the Clinic employee. Since EDs aren’t staffed with emergency psychiatric services on hand, even the in-house psychiatrists sometimes take hours to respond.

When asked about wait times at Billings Clinic for psychiatric care, Benoit said that the majority of patients receive a comprehensive psychiatric assessment within one to two hours of the assessment being ordered.

From there, it takes three to four hours to transfer the patient to an inpatient bed or external resources, but these wait times vary depending on inpatient bed availability or whether the patient is stable enough to be discharged.

When asked if hospital leadership was aware of their employees’ concerns regarding staff-to-patient ratios and what was being done to address the issues, Benoit responded with a description of the hospital’s staffing guidelines. He added that adjustments are made during each shift to ensure patients receive the care they need.

“Staff and patient safety are a fundamental duty of any health care organization and it is a continuous focus at Billings Clinic, as evidenced by our recent Leapfrog ‘A' safety rating and CMS 5-star Overall Hospital Quality Star rating. Everyone at Billings Clinic is empowered to raise concerns and work together to find solutions,” Benoit said in a statement.

Seeking certification

Hospital leadership has not given up on its goal of becoming a level I trauma center, despite recent layoffs and employee pay cuts.

Billings Clinic will lay off about 27 employees over the next 30 days

A few key elements distinguish a level II center, which Billings Clinic operates as now, as opposed to a level I center.

Level I centers conduct research and have certain specialists in-house at all times. They also must see a minimum of 240 severe trauma admissions per year in order to maintain the level I designation.

St. Vincent Healthcare is also reaching for the level I designation and will also need to meet the yearly minimum trauma admissions.

With all the changes happening at Billings Clinic, some employees say the ambitions of hospital administration seem to be more important than employee safety and satisfaction.

“A lot of the issues I feel are stemming from the fact that they are so hyper-focused on becoming a level 1 trauma center,” said one Clinic employee.

The employee recalled a moment during the height of a COVID-19 surge when hospital leadership boasted that a patient was being transferred from Tennessee to Billings Clinic for care. Dozens of other overflowing hospitals had turned down the transfer because they were operating far beyond capacity.

“Because we were told by administration, we cannot say no to any transfers, we accepted that patient from Tennessee … We were being forced to say yes when we were drowning,” the Clinic employee said.

When sick patients lined the halls at the hospitals, the community learned more about the practice of "ambulance divert" — a temporary status that signals to emergency responders that the ED’s resources are strapped and that the incoming patient needs to go to the other hospital.

Since then, the Clinic employee said hospital administration has barred the ED from going on divert, seemingly in an effort to maintain the patient volumes needed for level 1 trauma designation.

“So we could be absolutely destroyed in the ER — all the psych patients, all the holds, and we’re still taking patients from the Billings area and beyond,” the Clinic employee said.

When The Billings Gazette asked hospital leadership to comment on this claim, Benoit sent the following statement:

“‘Ambulance divert,’ a temporary status in which a hospital directs the local ambulance services to divert ambulances to an alternative hospital, is a last-resort measure that follows set criteria to activate when the hospital lacks capacity or capability to care for new patients. While hospitals across Montana face similar staffing challenges and rising patient numbers, as a non-profit rural referral center providing a range of complex care, Billings Clinic is committed to accepting patients when capacity and capability exists to care for them. As a result, we work extremely hard to avoid going on divert. If we have the capability, capacity and services available to care for the people who need us, we will find a way to do so, because they might not be able to get it otherwise.”

Benoit did not respond to several follow-up questions from The Gazette, which included questions about the number of times Billings Clinic went on ambulance divert in the last year, details about the conditions of divert and where psychiatric patients are sent if the Clinic were to go on divert.

'Worst time in history'

Staffing in EDs has always been complicated, according to Trestman, with the American Psychiatric Association.

Usually, when a patient shows up on the ED's doorstep, workers don’t have the option to turn them away. And when it’s time to transfer patients elsewhere in the hospital, the receiving department might not have the bed space or resources available right away.

Department leadership has to predict patient volumes at all times of the day and then try to schedule accordingly. It’s common for the ED to operate short-handed.

Focusing on the staff-to-patient ratios is almost irrelevant anymore, Trestman said, especially with the current staffing challenges in health care.

"This is the worst time for hospitals in our history," Trestman said. 

Without a significant investment from the government, it will be impossible to build up the therapeutic community services that bridge the gap between a weekly therapist visit and hospitalization, Trestman said. 

“We’re living the consequences of poor funding," he said. "Montana’s situation is being mirrored in the rest of the U.S.”

Trestman urges hospitals to engage in collaborative care by partnering with primary care providers to expand mental health treatment.

School screenings also help children keep severe mental illness at bay, he said, and leveraging telehealth for psychiatric visits expands access to the rural parts of the state.

Trestman is encouraged by the increased attention and discussion given to mental health in recent years. As a result, more treatments and technologies are being developed to support people in their darkest hours.

“That’s really exciting,” Trestman said. “That’s a really good thing.”