Hospital rejections of mentally ill patients spotlight failure of system

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The disclosure that two Lewiston hospitals were found to have illegally rejected patients who arrived at their emergency departments with mental health issues has highlighted a chronic lack of services for people with mental illnesses in Maine.

Behavioral health experts, hospital executives and law enforcement officials say the state’s mental health system is riddled with weaknesses and gaps in critical services.

The problems range from a lack of early-intervention programs that would stop mental health problems from becoming crises, to a dearth of outpatient services and inpatient beds. Simply put, there aren’t enough places for patients who are grappling with serious mental health problems but don’t need to be in a hospital emergency department.

“You either have the hospitals or jail,” Cumberland County Sheriff Kevin Joyce said. “Well, a lot of people don’t fall into either of those two categories. But there’s no other options, so people end up in one place or the other.”

In Lewiston, Central Maine Medical Center and St. Mary’s Regional Medical Center illegally turned away patients who were having mental health crises, according to state inspection reports that were posted online last week by Disability Rights Maine, a protection and advocacy agency for people with disabilities.

Both hospitals have since filed corrective plans with the federal government to avoid losing federal funding. Hospital officials described being overwhelmed with mental health patients and not having enough resources to help them as a reason they were turned away from the hospitals. In some cases, hospitals had “disruptive” mental health patients arrested.

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SUPPLY OUTSTRIPPED BY DEMAND

But the issues in Lewiston are symbolic of the lack of mental health services available outside of emergency departments and jails, experts say.

Joyce said 80 percent of the inmates at the Cumberland County Jail have a mental illness, and many would be receiving mental health services at other locations and would not be in jail if other options existed.

Some people are charged with misdemeanors so they can be in jail, with the understanding that the charges will be dismissed once they find a suitable mental health service, he said. In one case, an inmate stayed at the Cumberland County Jail 200 days waiting for a slot to open up, Joyce said.

“I operate the largest mental health facility in the state of Maine,” he said.

Thousands of Mainers are being taken to hospitals for mental health reasons every year, according to Maine Emergency Medical Services data compiled by the Press Herald. In 2017, there were 7,602 mental health transports by ambulances in Maine, about 2.2 percent of all ambulance runs.

After they arrive, some people stay weeks at hospital emergency departments — long after they’ve stabilized and don’t need to be in the ED — waiting for an inpatient bed to open up.

Dr. Robert McCarley, medical director for Maine Behavioral Healthcare Intensive Services, said bottlenecks occur at many points along the spectrum of mental health services. Those bottlenecks can cause patients to stay much longer than needed in hospital emergency departments.

“At this point, the demand is almost always greater than the supply,” McCarley said. “We need a system with much more resources than we have now.”

For example, Spring Harbor Hospital in Westbrook, which is part of Maine Behavioral Healthcare, has 100 inpatient beds for mental health patients — 60 for adults and 40 for children, McCarley said. But only about 10 become available each day, while there are often 30 or more psychiatric patients waiting in emergency rooms in the MaineHealth system, including at Maine Medical Center in Portland.

EMERGENCY ROOM IS ‘A HOLDING PEN’

Not all need an inpatient bed at a psychiatric hospital, McCarley said, but some need other services that aren’t readily available, such as outpatient services or something called a crisis stabilization unit, a place where patients can go if they don’t need to be in a psychiatric hospital but need residential treatment.

State Sen. Cathy Breen, D-Falmouth, whose adult daughter has a mental illness, said in the past two years that her daughter was stuck at emergency departments twice waiting for an inpatient psychiatric bed — once for nine days and the other time for five days.

“When you’re having a mental health crisis, being in the emergency room is clearly counterproductive,” Breen said. “It’s a holding pen. It’s the exact opposite of what most people in a mental health crisis need. We have a very broken system.”

Jenna Mehnert, executive director of the National Alliance on Mental Illness Maine, said the system has many shortcomings that need to be addressed, including a lack of prevention and early-intervention programs, and resources for those in crisis.

“The emergency department is far from the ideal place to go,” Mehnert said. “But it’s the least bad place that we have right now.”

Mehnert is advocating that Maine open up five “receiving centers,” also known as “assessment centers” where many people with mental illnesses could go when they’re in crisis instead of emergency rooms or jails.

Such centers are typically staffed with psychiatrists and nurses and support workers who specialize in mental health services.

Some states or counties have created these receiving centers, including Texas, Arizona, California and Pennsylvania, but they are not yet widespread.

Joyce said he also is looking at models in other states, including the one in Texas, to see if it makes sense for Maine. Joyce said he believes receiving centers could fill a gap in mental health services similar to how urgent-care centers can serve patients with problems that need immediate attention but don’t rise to the level of an emergency department visit.

Mehnert said the entire mental health system needs to be looked at. When Maine de-institutionalized in the 1980s and 1990s, the community-based system that replaced it was not well-designed.

“There is a lack of a real plan,” Mehnert said. “We do not have a robust menu of services.”

‘THE OPTIONS … ARE INSUFFICIENT’

Mehnert said there are 669 psychiatric beds in Maine, including long-term care for the most severely mentally ill, such as those residing at Riverview Psychiatric Center in Augusta and Dorothea Dix Psychiatric Center in Bangor.

She said it’s unclear what the average demand is for beds, but the demand exceeds supply.

Breen said the beds were not available for her daughter, even though her family had private health insurance, a reliable way to pay for the services.

Jeff Austin, vice president of government affairs for the Maine Hospital Association, said one of the big problems surrounding mental health care is the lack of reimbursement for staying at hospitals for mental health care.

If a patient has stabilized and is merely waiting for a bed to open up somewhere else, Medicaid often won’t reimburse the hospital for that time, even though it’s costing the hospital money. And if the patient is uninsured — a common occurrence among the homeless, for instance — trying to find a place where the patient can be safely discharged is even more difficult, Austin said.

“Every state is struggling with this issue,” Austin said. “The options we have in the community are insufficient to meet the need.”

Central Maine Medical Center (Sun Journal file photo)

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