New numbers highlight Covid-19’s impact on inpatient mental health care and emergency departments

New numbers reported this week suggest that inpatient psychiatric care capacity in Vermont slowly started…

New numbers reported this week suggest that inpatient psychiatric care capacity in Vermont slowly started to rebound last year, but still remains significantly below pre-pandemic levels. 

Meanwhile, the total number of days that patients seeking mental health care spent in emergency departments statewide reached new heights. That number, over 10,500 days, now appears to be more than triple what a similar analysis found as a baseline in 2015.

That result is not surprising to Ben Smith, medical director of the emergency department at Central Vermont Medical Center in Berlin. His department’s internal numbers show at least a doubling of inpatient days waiting for crisis mental health care over the last five years. The impacts on patients of all kinds seeking care and on his staff are profound, he said.

The increase has reduced his department’s capacity to respond to emergencies of all kinds because both beds and staff are occupied, Smith said. Also, “it’s terrible for these patients,” he said. “You couldn’t tailor-make an environment that is less therapeutic for someone in a mental health crisis.”

“It’s not because our staff isn’t there doing heroic work to try to keep these folks stabilized and comfortable,” he added. 

The stress of the situation, and the frustration, is causing people to leave to work elsewhere and leading to greater difficulty recruiting new staff to the emergency department, which is required to provide treatment to all comers. “We are the only place that can’t say no, and so our staff have to do this even though they know they are not able to deliver the right amount of care,” Smith said.

Representatives of both the state hospital association, which produced the new statewide data, and the Vermont Department of Mental Health, which made it public in an annual report to the Legislature, cautioned that while psychiatric care capacity and emergency department stays are related to each other, they interact in complex ways. 

“Inpatient bed capacity is, I would say, a major driver of why people are boarding in emergency departments,” said Emma Harrigan, director of policy analysis with the Vermont Association of Hospitals and Health Systems, which represents the state’s 14 hospitals, plus the Brattleboro Retreat and the Veterans Administration Hospital in White River Junction. “But we also recognize that there are other challenges that could be contributing to that.”

According to the new report, the number of people discharged by inpatient psychiatric facilities in the state increased over the previous year by about 10%. But a VTDigger review of the same reporting back to 2019 shows that the number of discharges remains more than one-third lower than prior to the Covid-19 pandemic. 

The overall days that patients spent receiving inpatient mental health care followed a similar trend, declining by more than half between the year prior to the pandemic and the height of the pandemic impacts in 2020 and 2021. The data released this week still shows a 30% reduction in the days of inpatient care provided in the period between Oct. 1, 2021, and Sept. 30, 2022, compared to the pre-pandemic era.

Other recent reports and presentations by Department of Mental Health staff to the Legislature describe an inpatient system still struggling to return to previous capacity due to local workforce shortages. 

Roughly 60% of each shift at the Vermont Psychiatric Care Hospital in Berlin is staffed by traveling nurses, and the department is relying on a traveling psychiatrist to keep the facility running at 21 beds, about 85% of capacity, Mental Health Commissioner Emily Hawes said earlier this month. The Brattleboro Retreat expects to return to its pre-pandemic bed capacity of 100 by the end of March 2023, but currently is able to care for only 84 inpatients. 

Meanwhile, the report showed the number of days that patients seeking mental health care were boarded in hospital emergency departments reached over 10,500 between Oct. 1, 2021, and Sept. 30, 2022, a new high. That number amounts to just a 5.6 percent increase over the previous year, but overall is almost 40% higher than the number of days tallied in the pre-pandemic 2018-19 period.

That baseline number of around 7,500 emergency department boarding days for patients seeking mental health care already reflected a system that was not meeting Vermonters’ needs. The hospital association has been collecting and analyzing the data going back over a decade, finding significant increases every year. 

“Even with the capacity we had pre-pandemic, we still had individuals boarding in emergency rooms,” Harrigan said.

In 2018, the organization reported just under 3,140 patient days in emergency rooms in 2015 and found an annual increase of almost 30% each calendar year through 2017, when it reached more than 5,200. Though the time frame is not directly comparable, this suggests that days spent in emergency departments in Vermont by patients seeking mental health care has more than tripled in seven years. 

Health regulators and state health care administrators have been focused on increasing the number of inpatient beds for both adults and youth since the Vermont State Hospital was closed following flooding during Tropical Storm Irene in 2011. Inpatient capacity had almost returned to pre-Irene levels in the year prior to the pandemic, with a push underway to have the University of Vermont Health Network add additional facilities to meet the growing need. 

This session, with those plans now scrapped, Gov. Phil Scott’s proposed adjustment to the current fiscal year’s budget asks for almost $9.3 million toward development of a youth inpatient facility at a medical center. 

Administrators acknowledge that staffing shortages have reduced available beds, and say they are working to re-open them and add more. But they also warn that it is a mistake to focus just on that number. Delays in moving Vermonters who need inpatient care out of emergency departments are due to a complex array of factors, including the lack of supportive longer-term residential alternatives so that patients can leave inpatient facilities.

“In the mental health system, we often say, ‘a bed is not a bed,’ because we may have beds that are not filled but, for various reasons, the placement is not the right fit to meet the needs of the individual,” said Nicole DiStasio, director of policy for the Department of Mental Health in an email.  

Another focus has been on creating avenues for seeking mental health care other than hospital emergency departments, and making sure that Vermonters know about them, DiStasio said. There is now a statewide crisis telephone hotline — 988 — that connects to mental health crisis support provided by designated social service agencies, with a contract to provide statewide community-based mobile crisis response expected soon.

More inpatient beds, however, would help those patients who are the most sick. Those are the people who end up in the emergency department for the longest periods, Smith said, comparing the result to not being able to send someone having a heart attack to intensive care. “It’s really, to my mind, a humanitarian crisis that is happening right here in Vermont,” he said.

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