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Lack of long-term care means mentally ill end up in ERs or jail

Mail Tribune - 11/14/2017

Nov. 14--Laurel Nickels sees the consequences every day of America's move to deinstitutionalize mentally ill people without providing enough care in communities.

"A lot of people were dumped out of the state hospital with nowhere to go," says Nickels, behavioral health services clinical manager at Asante Rogue Regional Medical Center in Medford.

Many people with severe mental illness are homeless, cycling through jail or filling up hospital emergency rooms and the limited number of psychiatric beds at local hospitals such as RRMC, she says.

At its peak in the 1950s, the Oregon State Hospital in Salem housed more than 3,500 patients.

Today, the state hospital has 678 beds at its Salem and Junction City campuses combined, according to Rebeka Gipson-King, Oregon State Hospital relations director.

Only 29 percent of those beds are occupied by people who have been civilly committed against their will, voluntarily committed or sent there due to the efforts of a legal guardian, according to Oregon State Hospital data.

The rest of the beds are filled with people who have been judged guilty of crimes except for insanity, as well as those accused of crimes who need mental health stabilization in order to aid and assist their defense attorneys, data shows.

A decade ago, RRMC's behavioral health unit averaged 12 to 14 psychiatric patients each day, Nickels says.

These days, the 18 beds at the Medford hospital are not enough.

"Now we're full every single day," Nickels says.

Those 18 beds aren't nearly enough to serve a coverage area that includes nine counties and 600,000 people, she says.

Asante has plans to remodel its Medford hospital to increase the number of behavioral health unit beds from 18 to 24. The additional beds could be available in two years, Nickels says.

Asante is expanding its number of psychiatric beds as a service to the community, she says.

With government and private insurance payments too low to cover costs, Asante consistently loses $1 million to $2 million every year running its behavioral health unit, Nickels says.

The movement to deinstitutionalize

Across America, state hospitals for the mentally ill were criticized for warehousing patients and employing practices considered by many to be cruel and extreme, such as lobotomies and sterilization.

The deinstitutionalization trend began in the mid-1900s, driven by the development of new psychiatric medications, financial incentives and the idea that patients would be better off getting care in community-based settings rather than large institutions, according to the national Treatment Advocacy Center.

But as the number of beds in state hospitals was slashed, not enough community-based care emerged to provide treatment and shelter for those with severe mental illness, according to the center.

The same scenario played out in Oregon.

Built in 1883 when it was then called the Oregon State Insane Asylum, the Oregon State Hospital has faced waves of criticism.

Well into the 1900s, it had a eugenics program and subjected patients to lobotomy, a procedure in which a doctor put a long needle or spike into a patient's brain and moved it around, severing brain connections.

In the 1990s, it was so crowded beds were placed in corridors.

During the 2000s, parts of the main Salem building were demolished, a new facility was finished and a satellite hospital opened in Junction City.

Without enough Oregon State Hospital beds to meet demand, local hospitals such as RRMC are struggling to provide enough care for psychiatric patients.

Nickels says some patients do need the high level of care that used to be provided on a larger scale by the Oregon State Hospital.

On the front lines

People experiencing a mental health crisis often end up in hospital emergency rooms.

The situation can be terrifying, especially for individuals and their families facing a first psychotic break.

Schizophrenia, for example, often strikes in the teen and early adult years, bringing on delusions and hallucinations.

"We see families in terror, grief and loss that the child they love is no longer present in the way they were before," Nickels says.

She can personally relate to the families.

Her son has schizophrenia, which she describes as a chronic, persistent and potentially devastating illness.

"He suddenly came to me with a very delusional story," Nickels says.

Fortunately, he has stabilized and is doing well, she says.

Nickels says the mentally ill patients RRMC serves are often amazing, creative, deep people who deserve the same level of care as people suffering from severe physical problems, such as diabetes or heart disease.

"The thing that fascinates me is how courageous and persevering people with mental illness are," Nickels says, noting they push on each day not knowing whether they can trust their own perceptions or moods.

RRMC has taken steps to try and ensure the safety of patients who come to the hospital in crisis.

It used to take 45 minutes to remove everything valuable and potentially dangerous out of an emergency department exam room. Then it would take another 45 minutes to put everything back after a psychiatric patient had left, Nickels says.

The hospital responded by placing equipment against one wall in its mental and physical health "swing rooms." A garage door-like moveable wall can come down, covering up the equipment in the specially designed emergency department exam rooms.

Nature photos on the wall are printed on vinyl, so there are no frames, glass or nails.

From the swing rooms, patients can be moved to psychiatric rooms that are also in the emergency department.

Called secure consultation rooms, they are furnished with a pull-out couch and a chair, more vinyl nature photos, a television affixed to a wall and a security camera.

A room for child patients has an added recliner so a parent or guardian can stay with the child.

Nickels says the hospital emergency department has seen kids as young as 5 years old with extreme mental health problems, including suicidal thoughts.

However, RRMC's behavioral health unit does not accept patients under 18. Children sometimes have to wait for days in the Medford hospital's emergency department for inpatient psychiatric beds to open up in the Portland area, Nickels says.

Some adult patients are admitted to the hospital's 18-bed behavioral health unit, where they receive psychiatric care.

Private insurance and government-funded insurance programs such as the Oregon Health Plan, Medicare and Medicaid don't pay enough to cover the cost of care, Nickels says.

Adding to the funding problem, they stop paying when patients are no longer an imminent danger to themselves or others, she says.

"We hold onto people and don't get reimbursed for much of that stay. But it's the right thing to do," Nickels says.

When people are eventually discharged, they have few options. There isn't enough residential care with supportive services in the community, she says.

"Sometimes we have to discharge them to the mission," Nickels says, referring to the Medford Gospel Mission homeless shelter. "Their prognosis is poor."

Searching for beds

Those who need to go to the Oregon State Hospital for longer-term care often end up waiting a month for a bed to open up in Salem or Junction City, if they can get in at all, Nickels says.

"That's part of the reason we're so backed up," she says.

With so few state-level beds, local hospitals throughout Oregon often have to take on patients from distant communities.

Most hospitals have no psychiatric units, leaving RRMC and hospitals in a handful of cities such as Coos Bay, Eugene, Bend, Portland and John Day to care for patients in their units.

Nickels says RRMC frequently has to turn patients away when its psychiatric unit is full. That sets off a scramble to find a psychiatric bed at a hospital in another city.

"We're having to remove people from their communities and their support systems just to get them into a safe psychiatric environment," she says.

The lack of beds also strains other community resources.

"Frequently there are no beds in the state of Oregon," Nickels says. "People are boarding in the emergency department because there are no beds."

The revolving door

For eight years, Tania Foster's son, now 22, has cycled from short-term psychiatric hospitalization to the streets to jail and back home.

As a teen he was diagnosed with bipolar disorder, which can cause severe, crippling depression and manic states that fill people with euphoria and energy, often causing them to engage in bizarre, disruptive behavior.

Foster asked that her son's name not be used.

In the early years of his bipolar disorder, he suffered most often from depression and tried to kill himself. The first time, he cut his wrists.

"Then he tried to hang himself from a tree in the yard with a dog leash. The leash broke," Foster says. "He took a bunch of pills and had to have his stomach pumped."

Since RRMC's psychiatric unit doesn't admit children, he was sent to a Portland facility. Once he turned 18, he was hospitalized at RRMC and other hospitals repeatedly.

"It's like a revolving door. He's not there long enough to get stable," Foster says, adding that his stays typically last about five days.

In later years, he has been experiencing more of the manic side of his bipolar disorder.

In his most recent incident of mania, he jumped in front of cars traveling on Riverside Avenue in Medford, causing them to stop abruptly to avoid striking him.

"It's almost like a high," Foster says. "You're invincible. He says, 'I'm being watched over. I'm safe.'"

With no beds open at RRMC's psychiatric unit, he was sent to a hospital in Bend.

During his stay at the Bend hospital, Foster tried to tell a Deschutes County civil commitment investigator her son's eight-year history of hospitalizations, arrests and suicide attempts. She told him about the incident of jumping in front of cars in Medford.

The investigator told her he would base his recommendation for commitment only on recent events and an interview with her son.

"Those with mental illness seem to be able to put up a front. People at the hospital say he's so intelligent. He helps with elderly people. He's super smart. For a while, he can fake it. He wants to get out of the hospital to be in mania," Foster says.

The investigator ultimately recommended her son go before a judge for a commitment hearing, but Jackson County Mental Health recommended against it, saying he didn't meet the state's commitment criteria, according to Foster.

"I don't think anyone wants to commit their child, but for his safety and the safety of others, what is needed is long-term commitment," she says.

He was released from the Bend hospital and returned home to the Rogue Valley, where he started a new job. Unfortunately, he was arrested again this month for running in front of traffic during a manic episode and had to be hospitalized again, Foster says.

Foster says her son has religious delusions and doesn't believe he is mentally ill.

"I'll try to give him shoes and he'll give them away. He feels he's helping people. He thinks he's a prophet and he should be preaching at church. My mom took him to church and he said he was a prophet who can heal people," she says.

Foster says people with severe mental illness need access to a long-term treatment facility. Although people point out such facilities are expensive, she says it's also expensive for the mentally ill to cycle through local hospitals and jails.

Her son has been banned from the Medford Gospel Mission shelter. When he is released from jail or the hospital on a cold night, he wanders the streets in a manic state, she says.

"It gives me such a hopeless feeling to try to find help for my son. There's no answer, it seems," Foster says. "Addicts can go to treatment for months and get clean. There's nothing like that for the mentally ill. Even criminals get to be warm and are fed. The mentally ill are put out on the street."

-- Reach staff reporter Vickie Aldous at 541-776-4486 or valdous@mailtribune.com. Follow her at www.twitter.com/VickieAldous.

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(c)2017 the Mail Tribune (Medford, Ore.)

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