While she knows better than to go to an emergency department for treatment of her mental illness, sometimes Katie Jones gets to the point where it feels there is nowhere else she can go.
“I don’t like to burden other people,” Jones said, “so I try to hang on as long as possible and figure stuff out by myself.”
But that approach doesn’t always work, and then, with nowhere else to turn and her symptoms spiraling out of control, Jones ends up in an ED somewhere, seeking treatment, support and help with her meds. Sometimes, those visits end with Jones being admitted to the hospital for psychiatric evaluation.
While those mostly short hospital stays help her find stability, there have been times after she’s been released where Jones has felt lost, with nowhere to turn. As the symptoms of her anxiety, depression and PTSD begin to ramp up, she looks for help, but often, in this vulnerable state, she encounters roadblocks that can feel insurmountable.
“A lot of times, when you reach out to a therapist or a psychiatrist, they tell you they don’t have appointments available,” Jones said. “They say, ‘We can see you in two or three weeks.’ It can even be months. The first time I heard that I felt, ‘I must not be that important. What am I going to do now?’”
So the cycle starts again. While Jones waits to see a mental health professional, her symptoms build, and before long, she’s back in the ED.
“About two and a half years ago I was in the emergency room seven or eight times in one summer. I knew it wasn’t the best solution to go there, but at the time it felt like it was my only solution. I didn’t know where else I could go.”
Starting this month, people like Jones seeking help for urgent mental health and addiction concerns will have a new option for care when M Health Fairview opens a transition clinic at M Health Fairview St. Joseph’s Hospital in St. Paul.
The clinic, said Rich Levine, M Health Fairview medical director of adult outpatient mental health and addiction services, is designed to provide key supports, including same-day appointments, medication management and connections to services for people struggling to make the transition to and from intensive treatment programs. The first of its kind in the state, it will be staffed by MDs, RNs, LCSWs and peer support specialists.
Levine explained that a typical route to the transition clinic will be through a referral from a provider.
“Let’s say someone came into one of our EDs,” he said. “They are severely depressed. They are having suicidal thoughts but they feel they can be safe with family.” Providers at the ED determine that this person isn’t a danger to themselves or others and doesn’t need to be admitted to the hospital, but they would be a good match for the more intensive treatment provided in a day-treatment program, for instance. The only problem is the next available opening is a week away.
This is where the transition clinic can help out, Levine explained: “The licensed mental health professional in the ED would call the transition clinic and say, ‘I have this patient. This is what’s going on. They have an appointment next week for day treatment. We feel they could use some help with therapy now to make sure things are still going OK.’”
Staff at the transition clinic could then schedule an appointment with a mental health professional that day or the following day. The idea is, Levine said, that the transition clinic can help people in that in-between gray zone make it safely through until they are stabilized or are able to move into more intensive treatment.
“We want to bridge that gap so patients don’t feel like they’re left alone to wait a week or two before that more intensive treatment starts. If they have a bad day, they might go to an emergency department to get care right away. Now, with this transition program, we will have providers available to work with them during this period so they don’t have to go to the ED.”
A better option
One obvious reason for creating a transition clinic is that it costs far less to treat a patient there than it does to provide similar care in an ED.
Allison Holt, chief physician, M Health Fairview mental health and addiction services, explained that staff at the transition program will be trained to understand their patients’ unique needs. In an ED, Holt said, staff are trained to provide medical triage and treatment for life-threatening physical injuries or illnesses.
“We’re trying to create a place where we can meet the person where they are at, rather than meeting them with the services that are available but don’t actually fit their need,” Holt said. It’s kind of like trying to shove a square peg into a round hole. The transition clinic’s approach, she continued, will be “really more patient-centered. It is also more cost-effective for everybody.”
Many people turn to EDs for treatment of their mental health concerns, Holt said. But many don’t get the care they actually need during those visits.
“At St. Joe’s last year we had 3,000 mental-health related visits to the ED. Only half of those visits actually resulted in admission. Half of the people who came in didn’t need hospital-level care but didn’t have anywhere else to go.”
Because it will employ psychiatrists and social workers as well as peer support specialists, the transition clinic will be able to offer a range of behavioral health services for clients, including assistance in making connections to key social service agencies, Holt said. Emergency treatment, by its very nature, is focused on responding to the crisis at hand, not at looking further out and building a healthier life. This reactive approach, Holt added, is not a helpful, long-term way to treat mental illness.
“Rather than treading water and reacting to every new need or issue that emerges, what most psychiatrists and leaders in the mental health field say is if we want to get out ahead of this problem we have to be proactive and create a better continuum of care that truly meets people’s needs.”
A reactive response to the state’s mental health crisis, Holt said, “like adding a ton of psych beds.” They might help immediately, “but not in the long term. We need to be proactive.”
A proactive approach, she continued, includes building connections with social service programs that already provide mental health and addiction services in the community and seeing what partnerships can be formed. With that goal in mind, she said, M Health Fairview has initiated conversations with leadership at a number of St. Paul’s largest nonprofits.
Jill Wiedemann-West, CEO of People Incorporated Mental Health Services, said she thinks there is clear need in the east metro for a program like the transition clinic.
M Health Fairview executives have, Wiedemann-West said, “a view of how they want to roll out this transition clinic and make it kind of an outpost for individuals in St. Paul in need of integrated care. I love that idea. It’s right up our alley. We’ve had conversations with them and I know they’ve also had conversations with other providers to talk about how we can collaborate.”
Because demand is high and the wait to see providers or enter treatment programs can be dauntingly long, Wiedemann-West said that EDs have become a default place for many people in crisis to seek help.
“The sad part is that emergency rooms have become holding areas for adults and kids experiencing behavioral health dysregulation,” Wiedemann-West said. “We don’t have beds for them. We don’t have housing. They end up getting stuck there in the ER, waiting, which is in so many ways unfortunate.”
She said she can only hope that a transition clinic could cut this cycle off at the knees for some people, and help keep them safely at home until they receive the care they so desperately need.
A fair replacement?
While Sue Abderholden, executive director of NAMI Minnesota, thinks that a transition clinic could offer key support to people on their way to or from treatment, she thinks a new clinic is no replacement for existing inpatient mental health and addiction treatment beds.
“My job is to be an advocate,” Abderholden said. “I want to make sure that people don’t hear this news and think, ‘Oh, isn’t this wonderful?’ This kind of program, while it sounds like a good step, isn’t a replacement for what [M Health Fairview has] closed down already. If someone needs hospital-level care, they need hospital-level care.”
The transition clinic will be open during business hours and not offer overnight services, Abderholden said: “What they’re talking about isn’t even urgent care.” She wonders if promoting a new program isn’t just a way to distract from significant cuts M Health Fairview has made to its inpatient behavioral health options.
“In a way it seems like the message is, ‘Let’s talk about how wonderful we are.’ Meanwhile,” if M Health Fairview proceeds with psych bed closures at M Health Fairview Southdale and St. Joseph’s hospitals, Abderholden continued, “they would close 16 percent of the inpatient psych beds in the metro area.”
Wiedemann-West said that M Health Fairview representatives have told her they have no plans to reduce the number of inpatient mental health treatment options at St. Joseph’s Hospital.
Levine said that M Health Fairview is trying to rethink the way it provides mental health treatment for its patients. “We’ve been working very hard to improve our access to therapy, psychiatry, programmatic care. We’ve made good strides on improving that access.”
By filling the gap many people encounter between care and long-term treatment, he explained, the transition clinic hopes to help patients get the care they need sooner.
“It’s a matter of supply and demand,” Levine said. ”Right now, we’re at a point where demand is higher than supply. We’re seeing gaps, with somebody coming in and asking for help and not getting that care when they need it. We felt that’s not the kind of care we want to give, and that puts the patient at very high risk. That’s truly why this transition program was created.”
One of the most dangerous times in mental health and addiction treatment is the period right before entering a treatment program or right after being discharged from one. In those moments, people struggling with mental illness or addiction are at a delicate point in their recovery. Too often, they are offered little or no help in making that transition.
Jones said that many times after being released from inpatient care she felt lost and on her own. Her struggles to schedule urgent appointments with providers when she was in the midst of a crisis often forced her to return to the ED.
“I would get a follow-up phone call two or three weeks after,” Jones said. This silence at a critical time put her at risk for relapse.
Levine said he hopes that the transition clinic will mean that more patients will be able to continue their recovery without experiencing that risky silence from their providers.
“We don’t want to lose the momentum between someone coming in and wanting help to actually getting them the help they need,” he said. “The transition clinic came in to make sure we bridge that gap.”
Some patients leave treatment thinking that they are “fixed,” and no longer need treatment for their mental illness or addiction issues, Holt said.
“They may start to feel like they don’t need help anymore. They might get busy in another area of their life that overtakes seeking mental health care. They might not have the ability to wait for several weeks just because they are already on precarious ground. That’s where staff at the transition clinic will step in and help keep them on track.”
Jones said that having a team of mental health professionals in her corner could have helped smooth her rocky path between treatment and long-term care. A few years ago, after a six-week inpatient stay in a psych ward, intensive support and assistance helped get her safely back on her feet.
These days, she thinks she’s finally on the road to recovery, working as a certified peer support specialist, but having a transition team in place following earlier hospitalizations might have helped get her to this point a little faster.
“The fact that in this new clinic, people will take the time to listen and formulate a plan and then touch base with patients is important,” Jones said. “Having that continuity of care is really essential.” The period of transition is, she added, “a very dangerous time to be out there. It takes an extra level of kindness and understanding to make it through.”