Filling the gaps: The challenges of mental health care in Scott County
Jordan Independent - 4/7/2018
Imagine waking up hours away from home and not understanding why you're there.
Imagine arriving at the emergency room only to learn the care and treatment you need is far away and comes with a lengthy wait list.
Being taken out of the community is a common experience for individuals suffering a severe mental health crisis in Scott County. There are no crisis stabilization or intensive residential treatment services - a type of short-term inpatient care for adults with mental illness - in the county. The Scott County Sheriff's Office regularly transports patients to cities across the state and beyond, including Mankato, Rochester, Duluth and even Fargo, North Dakota, to help people get the care they need.
"It's not uncommon for people at Prairie St. John's to wake up and think, 'Why the heck am I in North Dakota?,'" said Jeana Scheffler, a therapist in the adult inpatient unit at Prairie St. John's Hospital in Fargo.
While Scott County only utilizes hospital care as far as Prairie St. John's about four times a year, Scott County Sherriff Luke Hennen said it illustrates what limited resources look like.
"To me, it's a symptom of how mental resources in our state are not in equilibrium and how they are out of whack," Hennen said.
It's also a process bogged down with waiting.
The wait for care
The waiting can begin when a person arrives at the emergency room at St. Francis Regional Medical Center in Shakopee. Whether they arrive on their own, with a family member, or on a transport hold with law enforcement, Scott County residents in a mental health crisis almost always go there first.
If a patient at St. Francis is admitted to a unit at the hospital for inpatient medical care, the units are staffed to provide psychiatric care if needed. But the hospital will not admit a patient to solely receive psychiatric care, because there's no psychiatric unit, only support within other units. These patients are evaluated and boarded until appropriate care can be found.
This waiting, without treatment, for patients with mental illness at St. Francis lasted an average of 22 hours in 2017 - and it could last for days, according to data provided by the hospital.
"This is an issue that all ERs are trying to figure out," St. Francis Vice President of Medical Affairs Dr. Monte Johnson said. "ERs are basically the health care safety net in our society."
Emergency department physicians work to stabilize and assess patients. Allina Health's assessment and referral services support the physicians in determining the next step.
"Some communities have a mental health crisis assessment facility that goes along with IRTS and then you could skip the ER," Johnson said. "In Scott County, those people having a crisis at home will be brought to the ER. If an assessment facility was available, that process might change, but until then, the ER remains a very important part."
Scheffler said practices sometimes used in some ERs - such as mechanical restraints or sedatives - can be a setback to getting the person stabilized and home sooner.
"ER staff is not trained to deal with mental health crisis the way that mental health staff are," Scheffler said.
"If somebody is in a mental health crisis and our goal is to transition them back into their community, housing them four hours away where they are not near their family or friends or jobs or community is going to further impact their ability to get stabilized quicker," Hennen said. "It's not so much that it costs us a ton of money."
Once an individual is transported to a care facility, they may be getting right back into the squad car to be brought to their commitment hearing and then all the way back again a short time later. If a Scott County resident is being treated in Fargo, they may be picked up at 4 a.m. for a 9 a.m. hearing.
"Not only is it stressful for the deputies to have to make this drive twice, it can also be really hard for the patients to know they are traveling so far away from the hospital, only to return again that day," Scheffler said, adding she's often left scrambling to find her patients clothes and shoes they can wear to court.
"It just shows how painful it is and not responsive to the need of our community," Hennen said.
Delays in placing a person in a care setting may impact the patient's outcome.
"The earlier you get in, the better," Scheffler said. "The longer they are psychotic, the longer it takes to bring them back to reality."
The sheriff's office doesn't do all transports - only for those patients who wouldn't voluntarily seek treatment and their condition is so severe that they are considered a danger to themselves and others by a doctor.
While it may be difficult to get a place in hospital-level psychiatry care, it may be even harder to get out. According to Scheffler, patients often face two to three week waits to be discharged and placed in a lower level of care.
Filling the gaps
Intensive Residential Treatment Services facilities offer short-term inpatient care and crisis stabilization services. IRTS care is a step down from hospital-level care - these clients are more stabilized and don't meet the criteria for needing treatment in a locked hospital unit. These are the facilities that patients might transition into after their hospital stay.
In 2016, a study conducted by a Scott County Board work group identified gaps in the mental health care system. IRTS and crisis beds were identified as primary gaps.
Beds in these facilities are extremely limited even though there are over 30 IRTS facilities in Minnesota.
Director of Scott County Health and Human Services Pam Selvig is among Scott County officials pushing for a bill to pass the Legislature to provide $1.4 million toward building a proposed $2.8 million crisis stabilization and IRTS facility in Scott County - likely in Savage.
The steps toward the project began in 2016, when Guild Inc. - a nonprofit that provides treatment and services for people with mental illness - began working with Scott County to explore this possibility under an $80,000 grant from the Minnesota Department of Human Services.
In 2017, the executive director of Guild Inc. retired and Selvig said that delayed the project.
From Scheffler's perspective in North Dakota, Minnesota does a "great job" with mental health in general.
"It can be really hard to get people in Minnesota into an IRTS or into a crisis bed, however, in North Dakota, they don't even have IRTS facilities. They don't have group homes," Sheffler said. "There's really nothing for someone to step down to. Minnesota has way more services available, but the wait lists are a lot longer."
With a bill authored by Rep. Drew Christensen, R-Savage, and Sen. Dan Hall, R-Burnsville, moving through the Legislature with the support of some Scott County officials - including Savage Mayor Janet Williams - plans are moving forward again.
A bill authored by Rep. Tony Alright, R-Prior Lake, provides another potential avenue for funding. This bill includes $30 million in grants to be given out by the Department of Human Services for these kinds of building projects. If this bill passes, Scott County could apply for a grant for a facility.
According to Selvig, the proposed regional facility would offer short-term crisis beds for three- to 10-day stays, and IRTS beds for up to 90-day stays. There would be 16 beds total - a limit set by federal law to avoid large institutions.
Residents from outside of Scott County could also access care here - for example, Dakota County officials have discussed using the facility.
According to Hennen, a crisis stabilization and IRTS facility in Scott County wouldn't stop deputies from needing to do transports and it wouldn't cut down on the number of patients arriving at the ER - that step is so early in the process that it wouldn't go away.
It would, however, create more space in the care system and establish more inpatient beds that would be available to Scott County residents, and other patients from around the state.
From 2012 to 2016, Scott County saw a 100 percent increase in clients needing IRTS treatment - from 18 to 36 - and a 96 percent increase in clients needing short-term crisis beds.
"The reality is, we don't have anything here in the county for either of those programs or services," Selvig said.