Illustration by Mike Hirshon
On May 27, firefighters, police officers, emergency responders, and social workers pour into a meeting room at Metropolitan St. Louis Psychiatric Center. These are professionals trained to keep calm in a crisis. But they’re not calm now. MPC’s emergency department is about to close.
“Just what are we supposed to do with the psych patients we pick up daily?” asks city fire chief Dennis Jenkerson. Most do not come willingly; some can be violent. Their minds have spun out of control.
“Chief, we don’t know what to tell you,” admits Rob Fruend, CEO of the St. Louis Regional Health Commission, a collaborative organization that works to improve healthcare for the uninsured and underinsured. Tall, with friendly, squinty eyes and the rosy cheeks of a choirboy, he seems utterly guileless—but he’s reading every nuance in the room, plotting the group dynamics like a geophysicist predicting seismic shifts. He explains that the commission has formed this planning group to assess the closing’s impact and figure out how to respond.
Most of the agency officials around him are older—or seem older, years of frustration and resolve line-drawn on their faces. “The state is abdicating its responsibility!” they say. As these meetings continue, it will become a refrain.
On April 3, the Missouri Department of Mental Health announced that it was going to close MPC’s emergency department and inpatient beds. Instead of providing general psychiatric care, MPC would limit itself to forensic care, doing psychiatric evaluations for the courts and trying to restore competency to prisoners declared incompetent to stand trial.
And MPC’s previous patients? Community hospitals and mental-health centers would have to absorb the load: roughly 3,000 emergency-room visits and 1,500 inpatient stays a year, more than 60 percent uninsured, with 78 percent of the admissions involuntary.
The Department of Mental Health waited at least a year to take this step, hoping a community hospital would step forward as a partner. In Columbia, University of Missouri Health Care took over Mid-Missouri Mental Health Center; in Kansas City, Truman Medical Centers took over the adjacent Western Missouri Mental Health Center.
But the University of Missouri is funded by the state, and Truman is a public hospital supported by a local tax. The public hospital adjacent to MPC was St. Louis Regional Hospital, and it closed too.
None of St. Louis’ private hospitals wanted MPC.
So on May 19, Laurent Javois, regional executive officer for the Department of Mental Health, walked into a Regional Health Commission meeting and asked the group to pull local healthcare representatives together and make a plan to address the consequences of the closure.
If anything qualified as a community health crisis, this did.
Turns out, the crisis started long before April, and it’s far more complicated than an emergency-department closure. In the planning group’s early meetings, people remind each other that MPC’s patient volume isn’t high, so this won’t be as bad as it sounds.
But then the hospitals point out they’re already receiving about 17,000 psychiatric emergency visits a year, many of them riskier and more serious than the hospitals are equipped to handle. And the community mental-health centers say they’re so overloaded, some psych patients get discharged into free-fall—no follow-up appointment, no scheduled treatment, no caseworker to monitor meds or help with housing. Yes, MPC’s volume is relatively low: an average of seven or eight emergency-department visits a day, with a peak of 17. But that’s because MPC’s capacity has been slowly shrinking since 2000, from 112 patients to 50 max—and the overflow has been creating delays and danger at other hospitals.
“People keep coming to me saying, ‘I don’t understand what the problem is; it’s only seven or eight patients,’” Jim Hoerchler, social-work manager at Barnes-Jewish Hospital, informs the commission. “Well, I have four psychiatric beds, and at any given time, I have eight to 12 patients who need them. That’s without additional MPC patients.”
At SSM DePaul Health Center, psychiatric emergency-department visits are already up 79 percent over last year; at SSM St. Mary’s Health Center, 39 percent. At St. Anthony’s Medical Center, a steady stream of involuntary psych patients gets dropped off from surrounding rural counties. Not one of these hospitals is designed, as MPC was, to calm and treat involuntary patients.
Dr. Collins E. Lewis has worked in MPC’s emergency room for years, and he can’t imagine how other hospitals are going to absorb this load. “At least once every day, we have what’s called a Code Yellow, where you have to restrain someone who may be agitated or threatening. A patient may be down on the ground or struggling with the staff, and you have to know how to restrain him without hurting him or letting him bite you. You have to accept derogatory comments, so you don’t respond in a hurtful or harmful way. And you have to be hyperalert, watch the patients’ faces and body language. They may be sitting very calmly, and bing! They’re up and on you.”
Dr. Robert Poirier, chief of clinical operations for Barnes-Jewish Hospital’s emergency department, has had that experience more than once: One patient had to be tackled in the hallway, and others have smashed furniture or yelled threats, upsetting the critically ill patients around them.
“The majority of people with psychosis aren’t violent,” Poirier adds, regretting the old stereotypes this kind of discussion raises. “But we, of course, don’t see the ones that are pleasantly psychotic. And emergency departments just weren’t designed to handle high volumes of psychiatric patients. If a psych patient has to wait out in the waiting room for a while, they tend to get extremely upset. Anything can set them off—excess noise, a siren in the ambulance bay. At MPC, the staff is ready 24/7 if someone comes in violent. They have the space to isolate those patients. Even the colors on their walls are softer.”
Before the cuts, Poirier was pushing for a different solution: an internist on staff at MPC, so any coincidental medical problems could be handled without need for transfer to a regular emergency department. Instead, the state budget’s forced things in the opposite direction.
Joe (a pseudonym) was a National Honor Society scholar who played soccer, volleyball, tennis, and chess—also piano, guitar, and saxophone—at his private Catholic high school. He won four scholarships and went off to Drury University in Springfield. Sophomore year, he came home with an odd look in his eyes, patted his mother, and said, “Nice lady.”
Joe was diagnosed with schizoaffective disorder, which shows up in the late teens or early twenties. Medicine stabilized him, but at 26, after having diarrhea for six months straight, he stopped taking it. Eight months later, on a chilly day in November 2008, he was picked up on South Grand Boulevard, shirtless, clad in dress shoes, swim trunks, and a hockey helmet. He’d bought a gun. Police took him to the MPC emergency room; MPC admitted him and kept him, uninsured, for 11 days.
“We used to have too many psych beds in Missouri,” Poirier remarks. “Then hospitals cut back. Reimbursement for psychiatric care is fairly low, and the medication’s expensive. So now, you can have a patient in the ED for a day or two, just trying to find a bed open somewhere in the state.” If a patient comes in drunk or high, he adds, the emergency department has to wait 12 to 24 hours to see if the psychosis is still present after he or she sobers up. “And when a person gets stuck in an ED bed for 24 hours, that prevents me from seeing six more patients,” he says.
The Barnes-Jewish emergency department is full of stroke, heart, and head-trauma patients needing immediate treatment; psych doesn’t triage with the same urgency. The same’s true for Saint Louis University Hospital’s emergency department, and SLU does not admit involuntary psych patients; until now, if someone needed inpatient care, SLU transferred that patient to MPC.
The other community hospitals are fast realizing what a lousy deal the Department of Mental Health is handing them: Add security, do special staff training, redesign your emergency rooms to make them safe for potentially violent or suicidal patients—and in return, you’ll be alarming the rest of your patients, delaying their treatment, increasing your liability, and tying up precious beds for as long as two days.
As for the department’s favorite solution, privatizing MPC’s emergency department, SSM Health Care actually considered it.
“The state did everything it could to make the deal doable,” says SSM–St. Louis executive vice president John Eiler. “They were willing to help us with infrastructure, and I’m convinced they would have worked with us on a reasonable lease. But if you’re a stand-alone psych unit, you can’t get adult Medicaid reimbursement. We would have had to run it as a satellite of one of our hospitals. And then, anytime a patient makes a complaint of any kind, this will open the doors of the entire hospital for a potential state investigation. As we did the math, it was about $20 a day reimbursement over expense. So, for $20 a day for 50 beds, are you going to risk your 400-bed hospital in Bridgeton? We’re not in it for the money, but you have to have a sustainable service.”
The next jolt of adrenaline comes in June, when the Department of Mental Health announces MPC’s official closure date: July 15. The planning group’s Short-Term Crisis Management Team (or as Eiler dubs it, “Short-Term Panic Team”) has less than six weeks to come up with alternatives.
Another team is holding tense meetings, too: the Community Access Transformation Team that the Department of Mental Health created last year, back when it hoped to privatize MPC and thought it would have about $4.5 million left to spend on community care. Now that it’s simply closing the services instead, that figure’s dropped to $2 million, and the Community Access Transformation Team’s charge is to figure out how to allocate the money. Deadline: July 31.
The crisis management team starts rolling rocks uphill, creating protocols and standard practices so patient information can be shared, and finding community providers for many of MPC’s technical and legal services. But the biggest boulder—24/7 acute and emergency care for involuntary, uninsured, potentially disruptive patients—just won’t budge.
On July 15, the MPC emergency department’s doors close—and lock. Half of MPC’s 50 inpatient beds will be closed to the public by September, the other half by May 2011.
The emergency department at the Southeast Missouri Mental Health Center in Farmington also closes. And the Department of Mental Health continues playing musical chairs. It wants community providers to find housing for patients who’ve been living at the St. Louis Psychiatric Rehabilitation Center, so the center can focus exclusively on long-term forensic patients. Some of its “incompetent to stand trial” patients, meanwhile, will be sent to MPC—which will make room for SLPRC to take patients from Fulton State Hospital, which will make room for Fulton to absorb the recent influx of sex offenders crowding Farmington.
Why cut acute and emergency care and expand forensic care? First, because the state’s broke. Missouri received economic-stimulus money to ease its budget shortfall last year, and that money runs out next July. So Missouri has to close a $600 million gap by cutting from tax revenue that is not already protected and exempt—a pool of about $6 billion. Department of Mental Health spokesman Bob Bax says that given the life-and-death nature of its services, the governor is cutting the department as much slack as possible—it receives about 7.3 percent of the state’s 2011 general revenue and is only being asked to cut 3.26 percent of that. Still, over the past three fiscal years, the department’s had to carve $74.3 million out of its budget. Now, it’s cutting bone.
Second, forensic care is a constitutional mandate. Third, demand’s rising. The most conservative estimate of the number of inmates with serious mental illness is 16 percent; in 1983, it was 6.4 percent. A May 2010 report from the National Sheriffs’ Association and the Treatment Advocacy Center notes, “There are now more than three times more seriously mentally ill persons in jails and prisons than in hospitals… America’s jails and prisons have become our new
mental hospitals.”
At the start of its July 22 meeting, the planning group struggles, like kids with a greased pig, to get a grip on emergency care for the one group of forensic patients the state will no longer treat: jail inmates whose mental illness makes them dangerous to themselves or others.
MPC receives about 50 of these prisoners a year, from jails in 17 counties. Some are refusing medication, so they spiral into psychosis, and the jail infirmaries have no options left. Patients fall into three profiles: 1) young males with personality disorders, behavioral disturbances, impulsivity, and anger; 2) patients with a long history of criminality, deviancy, and antisocial behaviors; and 3) patients with schizophrenia or bipolar disorder who refuse medicine and tip into psychosis.
Now it’s looking like community hospitals will have to take those individuals—unreimbursed—as part of their general patient mix.
MPC had a locked facility, locked stairwells, locked elevators, a metal detector, and a secure interior courtyard. Community hospitals don’t even allow armed or uniformed guards on psych units, because it upsets the patients.
On May 17, 2009, Joe frantically called the police to report a (nonexistent) theft, then became combative. Luckily, instead of charging him with assault, the police officer took him to a nearby community hospital and asked for a 96-hour psychiatric observation and evaluation. The physician in charge said the assault didn’t warrant that long of a stay, says Joe’s mother, and Joe was discharged the next day. “They gave him a $5 bill and put him out on the road,” she says bitterly. “He started drinking, and that night, he was arrested driving backwards on I-44, going 50 miles an hour in reverse.”
In March 2010, Joe was arrested again, after whacking at his downstairs neighbor’s door with an axe, convinced the young man had been ransacking his apartment.
“He was always such a rule follower,” his mother sighs. “But the frontal lobe of the brain is where reasoning is done. Once he stopped taking his medicine, he got in all kinds of trouble.”
Unable to reach any resolution on the jail patients, the July 22 meeting turns back to fretting about emergency care for the rest of the involuntary patients. “MPC was purposely built to serve this population, and trying to put a plan together in six weeks is ridiculous,” bursts Hoerchler of Barnes-Jewish. “The overhead paging in my ED is, for these patients, one more auditory-command hallucination. What I do on a daily basis exacerbates their illness. I have a huge team of people back at my hospital looking at all this, trying to analyze the data and come up with a comprehensive solution. I am terrified that we are going to have catastrophes.”
With that, Mark Stansberry, executive director of BJC Behavioral Health, begins to argue for an extension to the Department of Mental Health deadline. The crisis team is supposed to hand the reins to a long-term planning team, yet it hasn’t solved the central problem of emergency and acute care for involuntary, uninsured patients. City officials are worried that if people go untreated, more will become homeless. Police officials are worried there will be violence.
“Those items that are not fully addressed need to be looked at by the long-term plan,” Javois, the Department of Mental Health representative, says calmly.
“We don’t have the luxury of waiting for a long-term plan!” Stansberry fires back. “I’m just saying there needs to be a better intermediate step.”
“Why can’t those ideas be put on paper and submitted with the plan next Friday?” Javois asks.
“Because I don’t think the hospitals are ready to do that,” Stansberry replies.
“Well, I’m sorry, but the hospitals had the opportunity to be part of this process,” Javois says.
“What if we had a major receiving center similar to Detroit’s?” Stansberry asks suddenly. People sit a little straighter, listening closely.
The Regional Health Commission’s Fruend now says what he’s known since he opened the meeting: “Some hospitals may be coming with their own resources on this one.”
A few people nod knowingly. Others look startled—and interested.
On July 28, local hospital CEOs formally propose a stabilization unit to handle psychiatric emergencies. They say they want to gather data and meet together, to see how it could be funded.
Three days later, CATT turns in the proposal the state requested, outlining ways $2 million could make next-day doctor’s visits possible, taking the heat off emergency departments, and reliably link patients back into the community when they are discharged.
The RHC crisis team’s report emphasizes the need for a stabilization unit to triage emergencies. With more than 20,000 psych emergency visits a year, the hospitals aren’t convinced stronger community care will be enough.
On August 2, Javois informs the commission that the state “has requested and expects only one plan from the region.” The state wants CATT and the crisis team to sit down and reach a consensus on how the $2 million should be allocated. New deadline: August 16.
Fruend zaps an email back: “Today’s request of the RHC’s team is new information from the State that has not been discussed with the RHC, nor agreed to by the RHC.” He offers not objections—he’s too politic for that—but caveats. The commissioners will not have time to study the CATT plan, so they will not be endorsing it. Members of the crisis team are free to comment as they choose, but RHC will not guarantee consensus.
At an August 5 meeting, Fruend tells the planning group what the state has requested. He also notes that a proposal is finally taking shape, at the hands of local hospital executives, for a stabilization unit. The topic just might come up on August 16.
“Just what is the source of revenue for this unit?” someone asks.
“We are pulling together a large group of hospitals to see if the hospitals will kick in money and then look at other ways of leveraging state and federal funds,” answers Hoerchler, the social-work manager from Barnes-Jewish. “The state is not able to collect Medicaid for MPC patients; depending on how you structured this, maybe it could.” (A federal law was passed years ago canceling Medicaid reimbursement to psychiatric institutions, because states were already providing those services to the uninsured.)
Tim (a pseudonym) “was going to a child psychiatrist when he was 5, acting out,” recalls his mother. “He was diagnosed as oppositional, then ADHD, then Tourette’s, then that went into bipolar, and now schizoaffective disorder.” Tim is brilliant, rarely compliant, frequently psychotic. His mother took him to MPC whenever possible. “My local hospital is worried about getting you in and out because of insurance,” she explains. “That doesn’t work with someone with mental illness. They have to get stable.”
At MPC, not only were the stays longer, but there was always an aftercare plan, she adds. After one community hospital stay, “the social worker gave him two pieces of paper with homeless shelters on them.” At another community hospital, the psychiatrist urged electroconvulsive therapy. “My son has so many problems now, I didn’t want any complications,” she says. But the doctor told her electroshock would give him a reason for keeping her son in the hospital.
What CATT wants to forge is a reliable link between acute and community care. When a community hospital discharges a psychiatric patient, it will have a phone number to call. The person at the other end will take responsibility for actively “pulling” the patient into community-based services, hopefully preventing further need for the hospital.
But will a next-day appointment with a psychiatrist be enough? How do you do in-home visits for someone who’s homeless? Can intensive case management and wraparound services be effective when a patient’s not compliant in the first place?
SSM’s Eiler was on the team of regional mental-health professionals that studied what healthcare providers call “frequent flyers”—a small group of individuals using a disproportionately large amount of psychiatric hospital days and other resources. The team’s January 2009 report totaled the cost of those resources for the region’s 291 highest utilizers in 2006 and 2007 as $14.9 million. That’s $51,202 per person.
The thinking was, get high utilizers into community care and pay closer attention there, and you’ll keep them out of the hospital. But the clinical team found “a higher level of acuity than anticipated.”
“We followed a small group of about 50 high utilizers,” recalls Eiler. “And we found the group was by and large resistant to participating. In very few cases did we actually connect anybody up with any services that did any good. Most of those folks don’t want those services. The exception is housing. But if it’s ‘Hey, I’m going to have somebody come and check on you every week’…no. It’s a myth that all you need to do is give the high utilizers more services. It’s inherent in their illness that they’ll resist that.”
He shakes his head. “Some of this stuff just makes me a little nuts. Yes, in a perfect world, mental healthcare in the community is ideal. It’s applaudable. But there are 20,000 mental-health ED visits a year. And nobody’s showing me anything that will prevent those visits.”
Melissa Hensley, a social worker who’s just finishing her Ph.D. at Washington University when MPC closes, recalls spending three weeks there in 1996. She was between jobs and had no health insurance, and she was overwhelmed by anxiety. Panicked, the only solution she could imagine was to end her life.
“I knew the hospital would keep me safe; that was the main thing,” she recalls. “I have a fairly severe case of bipolar disorder, and just taking one’s meds is really not enough.” Her three-week stay was average for MPC, but triple the average for a community hospital. “If MPC had discharged me earlier? I probably would have ended up back in the emergency room.”
August 16 arrives. At 1 p.m., the Community Access Transformation Team and the crisis team will sit down to negotiate. But first, they meet for three hours behind closed doors—definitely not the Regional Health Commission’s style. Fruend murmurs something wry about principles of transparency as he opens the formal meeting.
There are three options on the table. Option 1 spends the full $2 million on the community services in the CATT proposal. Nobody votes for it, not even that team’s members.
Option 2 gives $1 million to a modified version of that proposal, but holds off on allocating the other $1 million until October, when the hospitals will submit a proposal for an emergency stabilization unit.
Option 3 refuses to allocate any of the $2 million until stabilization-unit plans are complete in October.
Option 3 gravely displeases the state, which is already catching heat for cutting services. The option also terrifies community providers, who fear the state might retaliate by retracting the $2 million altogether. And it worries the softer hearts, who feel that if just one person is helped by spending $1 million now, that’s worth some potential loss in political leverage.
Feisty, well-respected Francie Broderick has been executive director of Places for People since it was founded in 1972, with the mission to provide housing and mental-health services to patients discharged from the old state mental hospital. She’s a community provider who worked with CATT, but she stands by Option 3. She’s well aware of the urgent need for services, she tells her colleagues. But she’s tired of the fragmentation and patchwork. “Either we’re going to build a system,” she says urgently, “or we’re going to keep adding pieces.”
Lesley Levin, president and CEO of clinical call center Behavioral Health Response, is still disgruntled that CATT did such hard work, only to be derailed by the big boys at the last minute. “This is the second or third deadline,” she says. “I think we may have run out of extensions. I’m in favor of Option 2. Everybody’s talking about playing chicken with the [state], but nobody’s talking about the people who will need services. If we keep waiting and waiting, and they are out there hurting…”
“We’re running on the fear that if we don’t take the dollars, they go away,” says another Option 3 backer. “I’m going to bank on the hospital consortium having enough clout that those dollars don’t go away.”
Well? Will they? Javois leans forward. “The department will not take a position that is absolute. Possibly, yes. Possibly. That’s not what we prefer.” Through the meetings, he’s been low-key, summoning force and dignity fluidly, as needed, then fading into the background again.
Now, frustration breaks through. “Think about all that’s not happening because of the closure of the ED,” he urges. “We’re getting complaints daily, and now we are saying, ‘Let’s not do anything for a while longer.’ Why couldn’t you do something now and still continue the planning?”
Sue Lindenbusch, executive director at St. John’s Mercy Medical Center, is unmoved by the state’s public-relations problem. “We can’t let the state off the hook for failing to provide for this population,” she says. “It would only take one hospital provider, you guys, to shut its doors, and behavioral health would have chaos. Two million dollars is nothing.”
Stansberry, who chaired CATT, says, “Many of you have come across with very compelling arguments for Option 3. It’s not compelling enough. I am fully supportive of a stabilization unit being developed. But stabilization alone, without a robust community system, isn’t going to be worth it. It will be good for 36 hours, 72 hours—then what?”
The next speaker begins, “If the state would just increase taxes—” and applause drowns the rest of his sentence.
And so it goes, some of the little guys deferring to the Department of Mental Health for the sure $2 million, others allying themselves with the clout of the hospitals and hoping for more.
Sgt. Barry Armfield, who coordinates the St. Louis County Police Department’s Crisis Intervention Team, holds his tongue as long as he can, then exclaims, “If we don’t have at least a place to take the seriously mentally ill that are a danger to the community, if I take them to the ED and they are released—and this has happened time and again—they are back on the street, and our second call is a SWAT team.”
Fruend of the Regional Health Commission takes a deep breath and suggests a break. Small knots of conversation form all over the room, with people discussing the stabilization unit as though it already exists. It has taken on the substance of an oar, tossed to a drowning man. Listening, Fruend perks up. In May, he thinks, it looked like the best the RHC could do was minimize damage. But if a stabilization unit could be created…
First, though, the state wants its consensus. Fruend reconvenes and asks those who support Option 3 what they’re hoping to gain by the delay.
“More money,” Jackie Lukitsch, executive director of the Alliance on Mental Illness/NAMI St. Louis, says bluntly.
Tim Dalaviras, executive director of Hyland Behavioral Health at St. Anthony’s Medical Center, leans forward: “The point is to show the state and the governor, ‘This is not enough; we are not giving you an easy pass on this.’ It keeps everybody at the table engaged. Once you start releasing dollars, the pressure comes off.”
“But the state can say, ‘We gave it to them, and they are not doing anything with it!’” Armfield protests.
Fruend sighs. “I told Laurent, ‘I’m reasonably good at this job, but I’m not sure I’m gonna get a consensus here.’ The department would like a vote.” As it’s taken, he says, “This is not a process of the RHC. We do not endorse the outcome of this meeting, and in fact we do not endorse this process.”
Everybody laughs. But the tension doesn’t melt.
The vote splits almost evenly: 11 for giving $1 million to community treatment and holding $1 million until a plan emerges for acute-care stabilization; nine for holding all $2 million until that plan emerges. But there’s an underlying consensus after all:
- The entire behavioral-health system in this part of the state is underfunded.
- We need both the community services in the CATT plan and one or more stabilization units, with emergency triage and beds for longer observation.
- The state’s deadline didn’t allow enough time to study the options.
- $2 million will not be enough.
August 19. About a dozen people straggle into the Regional Health Commission planning-group meeting—quite a drop from the 125 or so who flooded that first, panicked one.
“The report was submitted to the state at 8:30 p.m. Monday, with a midnight deadline,” Fruend announces. He’s wearing his usual crisp white shirt, sleeves rolled up but necktie in place. He’s still trying for brisk professionalism. But the mood around him is glum.
Bill Siedhoff, director of the city’s Department of Human Services, voices his distress that city representatives weren’t present to vote on the 16th.
“I think your police and fire representatives expressed that they felt their needs had been addressed,” RHC consultant Jennifer Brinkmann tells him.
“They shouldn’t have said that,” Siedhoff flashes back. He’s worried sick that if more psychiatric emergencies go untreated, more people will become homeless—and the homeless of the entire region head for downtown St. Louis, because it offers services they can’t find elsewhere.
“Do we know what the savings is from closing MPC’s ED?” he asks abruptly.
“I heard $5 or $7 million,” Places for People’s Broderick says. (Less, probably. Asked to confirm the number, Department of Mental Health spokesman Bax says, “What we are doing with MPC is part of a change statewide that will in the end save about $7 million, but that probably won’t be realized in total until the end of 2011.”)
“It’s a Band-Aid on an amputation,” Fruend mutters.
“What would you have voted, Siedhoff?” Broderick asks.
“Take a guess!”
She shrugs.
“I was in your corner, you know that,” he assures her.
Option 3, in other words.
“I think the state would have loved it if we had just said, ‘Oh that’s a great solution’ and taken the $2 million,” Fruend remarks, thinking back to Option 1.
“Oh, how do you run a department by letting people vote?” Broderick scoffs. “I think it’s just a way of not getting the blame.”
“I think it’s a data point,” Fruend says measuredly. “One data point. That’s why we were very careful to say at the beginning…”
“I think you have given enough disclaimers, Rob!” Broderick teases.
“This is their show, and I will keep qualifying this every time I can!” he rejoins.
Broderick turns serious. “You can’t separate out the parts,” she says slowly. “How many inpatient beds you need depends on how much community health you have. I just worry that we keep doing this in isolation and we aren’t going anywhere.”
“I have to agree,” Barnes-Jewish’s Hoerchler says. “We have so much knowledge, we have so many bright people, and we keep doing this. It’s like leaving one of the wheels off the car because we are hurrying to get on vacation.”
He and Broderick continue venting, and Fruend’s patience starts to fray. “You need to get with the rest of your behavioral-health leaders and take some initiative to collaborate instead of coming here complaining,” he tells them. “If you guys want to get together, meet together!”
“Oh, believe me, Rob, I am stuck to you like a tick,” Hoerchler says. But he’s missing Fruend’s point: The RHC is moving on.
“For different political reasons, people keep pulling the commission back into this,” Fruend says. “Which is OK—this is a big deal and a big crisis and we needed to step up. But at some point, we’ve got to move on to other pieces of the safety net.”
The commission’s new Regional Psychiatric Capacity Task Force, successor to the Short-Term Crisis Management Team, begins meeting in August. Unlike the initial team, which was made up of police, fire, hospital, and community experts dealing with emergencies every day on the ground, this group has senior-level executives who will focus, for the next three to five years, on long-term, systemic fixes. It’s led by Jim Sanger, president and CEO of SSM Health Care–St. Louis, who is keenly interested in this issue: SSM’s DePaul and St. Joseph health centers treat a large share—23 percent—of the area’s psych emergencies.
Sanger’s watched this issue morph, meeting by meeting. “First, there was a recognition that the problem was bigger than anyone had anticipated,” he says. “We really had a shortfall of service delivery prior to the closure of MPC. Secondly, as people have started to
talk, the range of possible solutions has actually grown.”
The new task force rakes in data and analyzes it in intense, two-hour meetings. It calculates that about 82 patients a day could be triaged at a stabilization unit, easing the load on community hospitals and treating patients who would have gone to MPC. Soon their ideal scenario emerges: Use the vacated MPC emergency department to triage psych emergencies and keep patients for 23-hour observation, with a satellite or two strategically located in the suburbs. Have specially trained psychiatric staff, security, and a calming environment.
In other words, re-create MPC—but with a few salient differences. The new unit would draw on the collaborative expertise of community hospitals and send seriously ill patients to those hospitals if they need a longer stay. And done right, the new unit might just be efficient enough to sustain itself.
Dr. Joseph Parks, chief medical officer for the Department of Mental Health, offers the loophole. A Harvard–trained psychiatrist in a bow tie who can outcrunch any statistician in the field, he informs the task force that if they keep the number of beds below 16, the unit will qualify for Medicaid and private insurance reimbursement. Above 16, it’s considered a psychiatric institution and is ineligible for reimbursement.
Galvanized, the group begins to discuss using the old MPC site as a “24-hour mother ship” and putting two satellites in the suburbs. But where? Members debate everything from a strip-mall location (ambulances to the back, for God’s sake) to an empty medical building. Then they hit upon the idea of using St. Louis County’s new health clinic and one of the Betty Jean Kerr People’s Health Centers. Remember the old hopes of integrating physical and behavioral treatment?
Startled by this proposal at the September 10 meeting, People’s CEO Dwayne Butler blurts that he’s already in the middle of a merger (with Hopewell Center). Over the next 10 minutes, though, he warms to the idea, noting that it might be possible to leverage federal funds. “Operationally, it would work,” he says at the meeting’s end. “I’m getting more and more excited as I think about it.”
At a side table, Hoerchler—who, true to his word, is attending every meeting—watches the team members nod slowly. MPC’s chief operating officer, Tony Cuneo, says he’s more than happy for the old emergency department beds to be used again. There are now several options for satellites.
All that remains is to find the funding—upwards of $2.3 million—and the crisis will be resolved.
