In the world of child and adolescent mental health, summers are usually a slow time. But this year, that’s not the case.
“The demand for our services usually coincides with the school year,” explained Todd Archbold, CEO of PrairieCare, a regional provider of psychiatric services for children and adolescents. This year, however, deep into summer break, PrairieCare’s inpatient facility in Brooklyn Park is running at capacity.
“Today we have 69 kids in our 71-bed hospital,” Archbold said during a recent interview. “It is a sign of the ongoing stress of the pandemic. Typically in July and August we are pretty quiet.”
This heavy patient load is not just a COVD-driven phenomenon, said Kyle Cedermark, M.D., a child and adolescent psychiatrist and PrairieCare’s chief psychotherapy officer. Statewide demand for inpatient mental health care for children and adolescents has been high for years.
“Every time we’ve expanded our bed capacity,” Cedermark said, “we end up running at almost 100 percent for the entirety of the school year, when mental health symptoms tend to flare up. There is a never-ending demand for inpatient services.”
Statewide, bed expansion hasn’t kept up with demand. In 2009, when PrairieCare opened its Minnesota hospital with 20 beds, Archbold said, “We immediately reached capacity. Later, we expanded to 50, and then 71 beds, and again immediately reached capacity. Even during the pandemic, we were at 99 percent capacity.”
Despite rising demand, the number of available inpatient beds for young Minnesotans has remained stagnant for years because of a statewide moratorium on the construction or expansion of inpatient mental health facilities. The moratorium, which was on all hospital beds and required a public review process for any new beds, meant that PrairieCare or other mental health providers without unused licensed beds were stuck at current capacity levels.
Last month, this picture shifted when the Minnesota Legislature approved a multimillion-dollar Health and Human Services Omnibus Bill waiving the hospital-bed moratorium and public interest review process.
With this new green light, Archbold said, his organization is moving ahead with a long-awaited expansion.
“We are going to add 30 more inpatient beds by the end of 2022,” he said. “We’ve already had meetings with architects. We will be expanding our campus in Brooklyn Center.”
If not us, then who?
The final, approved legislation opens the door for PrairieCare and St. Paul’s Regions Hospital to significantly expand their inpatient mental health beds.
Sue Abderholden, executive director of NAMI Minnesota, advocated with lawmakers to allow hospitals to add more beds. “The moratorium and public-review process is just one hurdle in adding more beds,” she said.
Regions was included with PrairieCare because the hospital was already at capacity with no unused, or “banked” beds, Abderholden explained. Since the legislation’s approval, the hospital has also announced plans to expand their inpatient mental health capacity. The busy urban teaching hospital, she said, “has to go to the Legislature every time they need to get extra beds. If someone like that is wanting to expand their mental health capacity, I want to make it easy for them to do that, not hard.”
This new legislation is welcome and needed, Cedermark said: “Without the moratorium, we would’ve done this expansion years ago. It was something we’ve been wanting to do for a pretty long time.” But he admits that he can’t let go of the reality that even with the moratorium in place, existing multipurpose hospitals with banked beds could have legally converted them to psych units and freed up space for young people in need of inpatient care long ago. Instead, those same hospitals were boarding young people in psychological distress for days or even weeks in ERs until space cleared up in facilities like his.
“We get this weird, discordant message of families, patients, NAMI and referring partners screaming about the lack of access in the state,” Cedermark said, “but then at the same time you get indifference from hospitals that already have the capacity to expand beds.”
Abderholden said she shares Cedermark’s frustration: “In many ways the moratorium wasn’t necessarily a barrier to building more beds. That’s partly because when the moratorium went into place, hospital systems were still able to keep beds. And a lot of hospitals have licensed beds that are not being used.”
Each fall, when demand for child and adolescent psychiatric services typically spikes, intake staff at PrairieCare start to hear from ERs looking to place young people who have been waiting in limbo until a psych room opens up somewhere.
As soon as school is back in session, Cedermark said, “We start getting the calls looking for space. It’s like these hospitals have just been keeping these kids in their ERs instead of taking them into their systems to treat them. But we’re often so full that we have to say that don’t have space for them.”
Legislators and advocates like Abderholden hope that expansions at PrairieCare and Regions will create much-needed space for people in need of intensive psychiatric care.
“We have all these children who are boarding in ERs,” Abderholden said. “We have adults who are going all over the region because beds aren’t available for them near their homes. That’s certainly problematic. To be far from home doesn’t help at all. We wanted to make it easy for people to do this.”
Even once the new beds are up and running, the state will still need more room for people in psychiatric distress, Archbold said.
“We’ve seen hospitals close. We’ve seen Fairview Southdale close their psych unit. And St. Joe’s program is still up in the air. Here we are, making progress in community-based services in this state, and we’re still seeing inpatient and residential capacity vanish. Especially for children and adolescents, we’re at capacity, and we will be for a long time.
Why aren’t the state’s hospitals expanding their psychiatric beds? Cedermark said he thinks it may partially be a matter of economics.
“I think it comes down to the relative profitability of mental health vs. programs like cardiology, orthopedic surgery, or labor and delivery,” he said. “Those are all considered better beds to have in your hospital. If you are an administrator and have the square footage, you will want to do something that will be more profitable.”
Viewed through an economic lens, Cedermark said, many hospital administrators consider mental health care to be a losing proposition.
“Every multidisciplinary hospital complains that their psychiatry group is losing money,” he said. But it doesn’t have to be that way: “Obviously, my organization exists as a psychiatric hospital that is growing and solvent. We’ve had one of our best performing years last year.”
Another reason some hospitals may be reluctant to expand their psychiatric services is that they don’t always make for good public relations, Cedermark said. Mental health care is, he said, “not sexy. It speaks to the vulnerability of the population.” Though he’s a big advocate for mental health care, he admits, “Even I’m self-conscious about how we market our services. We don’t want to be coercive. People have to have choice. It’s harder to create some cute ad campaign and flyer for services for the persistently mentally ill adults or adolescents who need this care.”
Abderholden believes that hospitals with banked beds that consistently board psychiatric patients are not fulfilling their responsibility to the communities they serve.
“I will say it does tick me off to have hospitals that are boarding in their ERs and are not seeing the need to add beds,” she said. “They are supposed to be responding to the needs of the community, period, and they’re not. They’ll say it is payment rates or it’s hard to find people to work in these programs. But what if those patients they were boarding in the ER had heart disease or cancer? You know they’d be adding beds then.”
Some local hospitals, including M Health Fairview Southdale and St. Joseph’s Hospital, have created options for treating people in mental health crisis that offer an alternative to emergency room care. These options, sometimes known as empath units or transition clinics, offer a more focused, less chaotic experience for patients.
While such programs are helpful and needed, Aberholden said they aren’t the answer to the shortage of beds in the state.
“Empath unis are just amped up ERs,” she said. “We already have places with psychiatric ERs. Regions has had one for years. It’s a very nice idea, but they can’t replace hospital beds.” Empath units can’t replace closed psych departments, she continued: “That’s what made me mad about Fairview Southdale. They closed their psych unit and created an empath unit. What about the people who need a hospital bed? If you need acute care you should be able to access it. You shouldn’t have to wait, and you shouldn’t have to go far from home.”
More room in the inn
Archbold is happy to finally be able to add 30 more beds to his hospital, but he also believes that the state can’t just build its way out of this situation. In order to get to a place where people in mental health crisis no longer have to wait days for an inpatient bed, he said, we need to start a little further upstream. If mental illness were recognized and treated in its earliest stages, it would be less likely to build to the crisis point, to where a young patient ends up in an ER.
“The solution is not having more beds, but ultimately it is that we need to reduce crises,” Archbold said. “What’s happening today with our 71 beds is that 90 percent of admissions are coming to us from the emergency room. Close to 1,500 kids in the state per year are ending up in a crisis at home, then 911 is called and they end up in a hospital ER. But that’s not the right place for them. Unfortunately, 90 percent of our kids are coming to us this way. This is not a thoughtful process. It is an overnight crisis.”
These new beds are needed, Cedermark said, but he also believes that earlier intervention could help many young people recover from their mental illness without seeking inpatient treatment.
“We are adding medically necessary beds for cases that have gotten past a crisis point and boiled over,” he said. “Some of these case could have been treated at an earlier stage to avoid going to inpatient care. I’d like to see expansion of less intensive programs, like partial hospitalization, day treatment programs. I believe that some of these situations are preventable.”
At PrairieCare, there’s been a renewed focus on nonresidential early-intervention programs, Archbold said: “We work hard with our outpatient clinics. We have six large partial hospitalization programs — we are the region’s largest provider of partial hospitalization services. We’re really trying to work upstream.”
It’s important to remember that even on the most optimistic timetables and aggressive hiring practices, these expansions are still more than a year away.
“It’s not going to be an immediate help,” Abderholden said. And even if multipurpose hospitals decide to add inpatient mental health beds from their store of unused beds, she added, “Banked beds are just a piece of paper. Hospitals will have to do construction to move banked beds to inpatient mental health beds.” If finding and hiring staff to work in these units feels like an obstacle, she added, “We’re hoping there is a more robust discussion about the funding and workforce needed, all of the things that prevent or are a barrier for current hospitals to add mental health beds.”
Once the 30 new beds are added, PrairieCare’s hospital bed count will just top 100. Though it may sound counterintuitive, Archbold said he hopes that there will come a time when some of the available beds will sit idle.
“I hope we build 101 beds, and a few years down the road we don’t need them all,” he said. “I wouldn’t see that as a problem. I’d actually see that as a good thing.”