It's no secret in the medical community that there is a shortage of treatment options for the mentally ill in Alabama. "We have a crisis in the state with how we treat the acutely mentally ill. There is a shortage of places to treat them and a shortage of places to send them for after-care," said Vernon Johnson, CEO of Dale Medical Center in Ozark, Alabama.
When many state mental health hospitals were closed during Governor Bentley's administration, there was a drastic cut to available beds in a state that was already struggling to care for the mentally ill.
"It was a way for the state to cut costs," Johnson said. "Also, they thought that many of the long-term patients who were in state hospitals could be reintegrated back into the communities. Now we have all these patients in the communities and we are struggling to service and care for them."
The increased demand to serve mentally ill patients is particularly difficult for rural hospitals that are already grappling with finances.
Cullman Regional Medical Center is not licensed for psychiatric care, but patients often come to the emergency department seeking care. "Resources for mental health patients are limited so you will see patients visit an emergency department because they can't access care anywhere else," said Charna Brown, RN, Cullman Regional Chief Nursing Officer. "Emergency room providers are tasked with identifying medical problems that mimic psychiatric illness. To differentiate medical illness from a psychiatric illness, we use an appropriate history, clinical testing, physical exam and a mental status exam. Psychiatric patients receive a thorough examination, but gathering a history or completing a physical can be more challenging depending on the patient's behavioral presentation."
If a patient is medically cleared, but still in need of inpatient psychiatric health care, they are often held in the emergency department until a transfer to an appropriate facility can be arranged. Cullman Regional has a full-time case manager to find those available openings, and because of the shortage, it isn't always nearby or convenient for family members.
Cullman Regional is taking steps to better serve this population and help them access an appropriate facility as soon as possible. In addition to hiring the case manager, the hospital has purchased a transport van to expedite transfers. "In the past, patients were often waiting on an ambulance to take them to a facility," Brown said. "We have also added a second security guard and we're working to recruit a psychiatrist to help us update our emergency room protocols in order to ensure we are providing the best care possible for these patients."
Unlike Cullman Regional, Dale Medical Center is licensed for psychiatric patients and has a 25-bed psychiatric unit, but they also have trouble finding long-term care facilities for those patients. "We have to get better at treating the acutely ill," Johnson said. "Even when the state mental health hospitals were open, they were at capacity and we had a backlog. The closings only made our problems worse."
Dale Medical Center contracts with SpectraCare Health Systems to take care of court-committed mentally ill. "These are patients who would have typically been sent to state hospitals," Johnson said. "We treat these patients and hope to have them stable and back out in 30 days.
"But there is a shortage of adult beds around the state. This causes a backlog in emergency rooms when people show up for care. We also have a backlog of mentally ill people being held in jails. They can't be released because there's no place to get them treated. We service five counties, and our unit is at capacity."
Johnson said the problem can only be solved by getting all parties to work on a solution. "The Alabama Hospital Association and the Department of Mental Health are working closely with the commissioner of mental health. We are also working with probate judges and sheriffs, trying to get all the principals around the table. Unfortunately, there is no funding to help with these programs. At some point in time, funding is going to have to be addressed at the state level to help us manage the situation."
One avenue for that funding would be Medicaid expansion. "We have the most restrictive Medicaid program in the country," Johnson said. "It's hard to qualify for it unless you are a child or a pregnant woman. A lot of extra dollars would come here with Medicaid expansion that we could apply to those patients with no coverage. It would help them maintain their treatment, help them with medication and take the burden off the hospitals for the uninsured. Medicaid expansion would have a huge positive effect in assisting with this crisis."