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Ohio has 'critical' shortage of psychiatric hospital beds

Hamilton Journal News (OH) - 3/1/2015

March 01--Millions more Americans suffering with a mental illness are gaining health care coverage, but there aren't enough medical providers to keep up with demand.

"Coverage does not equal access," said Dr. Marcus Romanello, chief medical officer of Fort Hamilton Hospital. "There's a relative shortage of psychiatrists with availability to see new patients."

In addition to the Medicaid expansion, 6.8 million uninsured people with a mental illness are gaining new health coverage under the health care law, between 2014 and 2019, according to a 2012 report from the National Association of State Mental Health Program Directors.

In the U.S., one in four adults has a severe mental health need, but only a third of the affected population seeks out treatment.

"Psychiatric illnesses are the No. 1 public health problem in the U.S.," said Dr. Paul Keck, president and CEO of Lindner Center of HOPE and endowed professor of psychiatry at University of Cincinnati College of Medicine.

But the national cohort of about 49,000 psychiatrists is aging -- ranking as the second oldest group of physicians -- and not as many young physicians are opting to enter the specialized field, according to the National Institute of Mental Health.

In 2012, slightly less than 4 percent of graduating students chose psychiatry, according to Dr. Thomas Insel, director of the National Institute of Mental Health, in a blog post.

"There are too few people to take care of the overwhelming demand for services; it's a national crisis," Keck said.

Linda Pastore, who lives in Butler County, said her 32-year-old son was diagnosed with schizoaffective disorder, a combination of bipolar disorder and schizophrenia, around age 25. Her son has received inpatient care at several hospitals following manic, psychotic episodes.

"The difficult part was when he was released there weren't many psychiatrists taking new patients," Pastore said, who found one through a social worker.

Reasons for a shrinking pool of psychiatrists include a high rate of student loan debt with one of the lowest mean incomes in medicine and low reimbursement rates from insurance payers, Keck said.

"There's a relative fiscal disincentive," Keck said. "The whole reimbursement model has been skewed toward procedures. (In psychiatry) you're billing for time spent with individuals embarking on evidence-based treatment plans. The value of that has been gradually marginalized by payers."

Shortage of beds

Across the nation, the rate of inpatient psychiatric beds has plummeted to 1850 levels. There were over 558,000 public psychiatric beds in 1955 -- which declined over 92 percent to around 43,300 beds by 2010, according to 2012 data from Treatment Advocacy Center.

Ohio is one of 11 states to have a "critical bed shortage" for mentally ill patients needing hospitalized, according to the national nonprofit Treatment Advocacy Center.

Ohio -- which lost 152 beds between 2005 and 2010 -- has only 18 percent of the beds necessary to meet the needs of its population with severe mental illness, said Jamie Mondics, spokeswoman for Treatment Advocacy Center.

"To improve the care of people with severe mental illness, states need to improve their civil commitment laws and restore psychiatric beds to meet the needs of the population with severe mental illness," Mondics said.

There are about 85 public and private inpatient psychiatric beds available in Butler and Warren counties, according to hospital officials.

Those beds are spread out across Fort Hamilton Hospital (20); Lindner Center of HOPE in Mason (32); Beckett Springs in West Chester (24 and growing); and Atrium Medical Center in Middletown (nine).

Fewer dedicated psychiatric beds means unintended consequences of more patients turning to emergency departments for care, higher rates of homelessness and more mentally ill in jails and prisons, according to Treatment Advocacy Center.

At Fort Hamilton Hospital, there's also a dedicated four-bed unit in the emergency department to hold patients longer for mental health evaluations, Romanello said.

The Hamilton hospital records 43,000 annual visits to its emergency department -- with about 3,000 requiring a mental health evaluation, Romanello said.

Romanello said the psychiatric unit at Fort Hamilton usually has 12 patients admitted. He said there's not enough staff to have all 20 beds filled.

Romanello said a crisis worker acts as the "key driver" to finding the patient an open psychiatric bed at nearby hospitals, or across the state, if Fort Hamilton is at capacity. He's sent patients as far as Columbus and Cleveland.

Romanello said a patient awaiting transfer has an average stay of six hours in the ED.

"It requires the devotion of a nurse to that patient; it ties up resources," Romanello said.

There are six state psychiatric hospitals across Ohio, including Summit Behavioral Healthcare in Cincinnati, said Dr. Mark Hurst, medical director for the Ohio Department of Mental Health and Addiction.

There are about 1,065 beds available at the state hospitals, and they run at 90 percent capacity.

"We are the safety net for the state of Ohio; we take uninsured people private facilities don't have resources to meet their needs," Hurst said, with 7,000 patients admitted in 2014.

Pastore said about three years ago her son was hospitalized in Fort Hamilton's psychiatric unit and eventually moved to the state's mental hospital in Cincinnati for six weeks. He wasn't on any medication at that time.

"In the beginning, he didn't believe he was ill and didn't want to take medication," Pastore said.

Pastore's son has been taking medication for about a year now after spending five weeks at Beckett Springs in West Chester Twp. last year.

"He had gotten so very sick and scared of what was happening," Pastore said. "He had a very good experience there. They set him up with a good plan for home health."

The Lindner Center of HOPE in Mason, a mental health and addiction center, has an average inpatient stay of seven days. Keck said the patient goes through crisis intervention, is stabilized enough to be safe, and then discharged with close follow-up care.

Keck said the mental health needs vary greatly -- from mood disorders, bipolar disorder and depression, traumas, eating disorders, anxiety and substance abuse.

Romanello said it's estimated that a fourth of emergency department visits have an underlying psychiatric concern.

"The iceberg is bigger than we even know," Romanello said. "As each hospital looks to serve their community; they should consider mental health as a priority."

Shortage of providers

There are more than 96.5 million Americans living in shortage areas for mental health providers, according to a November 2014 report by the U.S. Department of Health Resources and Services Administration.

There are about 4,000 designated mental health professional shortage areas in the U.S., with about 125 in Ohio, said Shane Ford, researcher for Ohio's Primary Care Office responsible for overseeing the shortage areas.

The designation is bestowed for a variety of reasons, including for geographic areas, low population to provider ratios, low-income or Medicaid-eligible populations, or facilities such as a prisoner or federally-qualified health center.

In Butler and Warren counties, three designated shortage areas include the nonprofits Primary Health Solutions and Talbert House and the Lebanon Correctional Institution.

"The designation ... is intended to allow them eligibility for recruitment and retention programs," said Coleen Schwartz, administrator of Ohio's Primary Care Office.

Marc Bellasario, CEO of Primary Health Solutions, said his agency got the designation automatically due to being a federally-qualified health center. It helps with recruiting people to the area by offering some loan forgiveness.

The Ohio Department of Health receives approximately $400,000 annually from physician license renewal fees to support its Physician Loan Repayment Program, Schwartz said.

Ohio's program is currently supporting 35 providers across the state, including psychiatrists, psychologists and social workers. The workers receive debt repayment assistance up to $50,000 for two years of service in shortage areas.

Hurst said the state hospitals also have a hard time recruiting and retaining qualified staff. He said in the last three years they've hired more allied health professionals, such as psychiatric nurse practitioners and physician's assistants, to fill in the gaps.

"We were having substantial problems with recruiting and keeping psychiatrists," Hurst said.

At Fort Hamilton Hospital, only one psychiatrist and one psychiatric nurse practitioner is on staff. Romanello said the hospital hopes to expand its psychiatric coverage with a second physician.

"Historically it has been difficult to recruit because there's such a severe need across the country," Romanello said. "Technology stands to improve the situation. Telepsychiatry is beginning to robustly develop."

Romanello said the Kettering Health Network that operates Fort Hamilton has been launching tele-crisis consultations across its hospitals. Fort Hamilton will be getting the service next month.

Solutions

The Treatment Advocacy Center said the increased use of community health centers and outpatient services will continue to quell the demand for inpatient beds.

Keck agrees that providing "good, quick" access to outpatient treatment options can help a patient avoid the later need for hospitalization.

"You always want to treat a mental illness as early as possible," said Scott Rasmus, PhD, executive director of the Butler County Mental Health Board. "The earlier the intervention for a mental illness, the better prognosis."

The Lindner Center of HOPE receives 600 calls a month for outpatient care, but staffing levels only allow them to accept 60 new patients, according to Keck. They will often refer patients to outside agencies also faced with high levels of capacity.

Kimball Sticklin, CEO of Butler Behavioral Health, said the agency offers comprehensive outpatient services to those with mental health and addiction problems. They serve about 4,500 people each year.

Butler Behavioral Health has six psychiatrists on staff, as well as nurse practitioners, a physician's assistant and registered nurse.

Primary Health Solutions contracts with Butler Behavioral Health for mental health services in Butler County. A behaviorist will see patients on the spot at clinics in Hamilton and Middletown, Bellasario said.

The behaviorist assesses the patient's need for therapy or to see a psychiatrist. Bellasario said they also now screen for depression and substance abuse problems in an attempt to catch a problem before it balloons into a crisis.

Pastore said while her son has a high school diploma and college degree, he's not been able to work due to his illness. He receives supplemental security income and disability.

Pastore said in recent years she and her husband have become advocates for their son through education and resources from Butler County National Alliance on Mental Illness.

"If you don't have an advocate, you're not finding help," Pastore said. "Just like any other illness ... when your family member gets a diagnosis you help them."

Another safety net to improve a patient's likelihood for success after hospitalization is a group home setting to step down to, said Chris Reese, a social worker and residential placement coordinator at Community Behavioral Health.

Reese said he works with clients before and after hospitalization to coordinate placement in group homes in Hamilton, Middletown and outside of Butler County. He placed over 150 clients in group homes in 2014.

"You hear talk of providers wanting to build more facilities and beds but until then ... it's kind of a juggling act," Reese said. "Butler County is ahead of the curve; as much as a problem it is, if you look at other counties we're ahead."

Community Behavioral Health also leases space inside Fort Hamilton Hospital to operate a 15-bed residential facility called Great Miami Services. It's a step-down program from hospitalization with 24-hour staffing and weekly access to a psychiatrist.

"It's a time to focus on you starting over," Reese said. "If you're at a hospital and have nowhere to go. You don't have to worry about where your next meal is."

Keck said a mentally ill patient is at their greatest risk for suicide within 30 days of discharge.

Reese said a stay at Great Miami Services ranges from one to four months before moving to a more independent setting like a group home.

Pastore said her son is living at home now due to what she says is a lack of quality, supportive group homes in the area. She said there's also little access to therapy or programs for life and behavioral skills.

"There's not the next piece of how to manage your life," Pastore said.

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(c)2015 the Journal-News (Hamilton, Ohio)

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