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COUNTERPO!NT • FALL 2017
NEWS
ED WAIT TIMES SOAR • Continued from page 1 said she expects the department will make “some pretty clear recommendations that would alleviate some of the tensions” of emergency room backups in the AHS December 15 report. The larger question that faces the state, she said, is “Are we going to be able to do more with less?” referencing a budget shortfall that will be a barrier to building more community supports. “That’s a resource issue,” she said. On a daily basis, just the number of people being held involuntarily in an emergency room in September averaged 11, compared to five in June. September data was the most recent available from DMH before Counterpoint went to press. Between June and September, the length of waits almost doubled for involuntary patients who did not get admitted within their first two days in the emergency room, increasing from an average of 114 hours (4.7 days) in June to 218 hours (nine days) in September. The average wait for those admitted within the first two days has remained at about 13 hours. Involuntary holds, called emergency examinations, also increased to a new high in the July-September quarter: Paperwork was filed to mandate admission to a hospital for 177 people. Vermont Psychiatric Survivors is researching the reasons people are showing up in emergency rooms, and according to executive director Wilda White, the early evidence is confirming that many of the reasons listed in medical records are not why they actually came. “Their case manager is telling them to go to the ED” with very few attempts to talk them through a momentary crisis before calling an ambulance and police. “This happens over and over and over again,” she said.
Deadline Criticized The legislature called for an analysis and action plan “in order to address the present crisis that emergency departments are experiencing in treating an individual who presents with symptoms of a mental health crisis, and in recognition that this crisis is a symptom of larger systemic shortcomings in the provision of mental health services statewide.” White said that research VPS is doing to identify the issues and needs will not be completed in time for the report under the deadline the legislature set. “I resent that the legislature passed an arbitrary, unreasonable deadline,” she said. “I prefer quality research that actually responds to the problem.” “If it [the legislature] gets crap, it’s because it passed crap” by giving inadequate time and no money for a real analysis, 200 White said. Bailey disagrees. She said that while there is 180 always room for more data, a response to the 160 crisis cannot wait for completion of research or data collection that is still 140 underway. Deputy Commissioner 120 Mourning Fox said that “having an artificial 100 deadline imposed” by the legislature was a positive 80 FYQ1 2015 FYQ2 2015 thing, because otherwise “analysis paralysis” can
block taking essential action. Bailey said DMH invited a broad mix of people to provide input, and sits in the middle between voices of “peers and families and advocates” and very different voices from places like law enforcement and the courts, which often express frustration when individuals are not admitted to a hospital. Input from providers has focused on claiming needs in three main areas: more inpatient beds for patients with the highest potential for violence; a reduction in the length of inpatient stays by speeding up the use of court orders for forced drugging; and increased resources in the community, especially in supportive housing. The report will respond to a specific question raised by the legislature about whether the legal process needs to be changed to allow petitions for forced medication orders to move more quickly, Bailey said. While not offering details, Bailey said in terms of scope, “We’re talking about the tippy top of the triangle” among individuals with mental health needs. “There are these really intense cases where the delay is not helpful,” she said. “It’s about getting to the right treatment” in those cases where medication is what is appropriate. White said that VPS has committed to several projects that will help to develop better understanding of underlying issues. Focus groups will be underway shortly to assess individual perspectives on using the ED. That will supplement in-depth interviews and chart reviews that White has been conducting. She said these have already demonstrated two things: that clinical records do not match what people say are their real reasons for going to the ED, and that often, orders of non-hospitalization are what actually cause a person to go into crisis. An ONH is a court order that sets out conditions for a person’s release from a hospital and can be renewed annually. “The trauma of the ONH is causing [the] problems,” she said. “They get so upset about the ONH.” If actual problems are not being identified, “the problem is not solved when they are released,” White said. She has heard patients identify problems that range from having had a fight, to not feeling safe in a home situation, to needing a shower or wanting a hug. VPS is also working on an audit of the designated agencies to identify whether they are using best practices in their service delivery. That review is being conducted by a doctoral student, White said. Research is underway on two data pieces sought from hospitals by both advocates and
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legislators, but these data will not be in place by December either, according to Devon Green from the Vermont Association for Hospitals and Health Care Systems. Emergency room data on the numbers of people waiting, and how long they wait, includes only those individuals who are being held involuntarily. There are also no data about how frequently people are subjected to restraint because of a crisis while waiting for an inpatient bed. Green said “there is progress” in meeting the commitment by the hospitals to gather data. In both categories, providers needed to work out definitions, such as “What constitutes a patient with a mental illness waiting in an ED?” Now that there is agreement on language – for the wait times, the data will reflect people “ready to be admitted or transferred, but that’s not happening” – capturing the information in both categories will be underway shortly, Green said.
Admissions Question White presented initial national background research on characteristics of people most likely to experience long waits at meetings last summer. Her report led to a question at one public hearing about whether hospitals could refuse to admit some types of patients, contributing to those waits. DMH data shows that there are often inpatient psychiatric units with vacant beds while some patients wait in emergency rooms. According to White, officials at DMH “said very authoritatively that there are no restrictions” on hospitals refusing an admission. She said she contested the statement and wrote a follow-up letter outlining the admission requirements under federal law. White said that in a meeting last month with DMH and hospital representatives in response to her letter, no one disagreed that there must be a clinical justification to refuse admission. She said she doesn’t think highlighting the federal law will make a significant difference in access. “I do think that if they [are] aware that people are keeping a close eye,” it will help, she said. Hospitals cannot refuse admissions based on the fact that a person “is here all the time,” has criminal justice system involvement or has a particular diagnosis. Identifying the justification is crucial for reasons other than a specific admission, she said. “The most critical information we need,” she said, is to document the clinical reason for refused admissions to identify solutions that “serve people with complex needs” who aren’t (Continued on page 5
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Number of people held for an involuntary admission to a hospital.
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