I stared at the Excel sheet and looked at the first person on the list. She was in her mid-40s, single, white and had been to the emergency room over 38 times in one year.
As the medical director for quality at a community hospital in Metro Detroit, I and several members of our staff met with our local community mental health agency to figure out how many of our Medicaid patients were both high utilizers of our emergency room and had a behavioral health diagnosis.
I reviewed the medical record of Ms. X, the woman at the top of the list. Her chief complaints varied from headaches to back pain to abdominal pain. She was never admitted to the hospital, but her ER visits always consisted of expensive imaging studies (CT scans, MRIs, etc.), lab work and her demand that her pain would require narcotics. Behind the medical complaints, the patient’s past medical history included a diagnosis of anxiety and substance abuse.
We concluded that her persistent visits were most likely due to an underlying narcotic addiction combined with an anxiety disorder: she would present with a physical problem in order to gain access to the narcotics to which she was addicted. Several of the patients on the list had similar stories, but others were “frequent flyers,” due to repeated suicidal attempts or exacerbations of an underlying psychotic condition.
We adjourned our meeting with an agreement to develop a process to have these patients identified in the emergency room and then evaluated by a mental health social worker, in hopes of diverting them to a behavioral health setting where their problems could be appropriately addressed.
Working on this project revealed how greatly we need reform of Michigan’s mental health system. I am not a psychiatrist, but as the person responsible for quality healthcare in my hospital, I feel that, if I am being held to providing the best possible care for our patients, the current policy dynamics that need to be understood and addressed.
Cases like Ms. X’s forced me to study Michigan’s public mental health system and what I found is an underfunded and decentralized system that cannot hope to achieve the goal of providing services to the most vulnerable members of our society.
A decentralized system
The project I worked on at my hospital is based on the collaboration of one community hospital in one county to identify and appropriately treat this subgroup of patients.
What about the patients from other counties that make it to our emergency department? What about the same county patients who are seen at neighboring hospitals not involved in our integrated process? Pilot projects can be educational before committing to a major initiative, but, why isn’t the state developing a similar project that involves all counties and all major health systems in Michigan?
Prior to my work on this project, I had little to no understanding of how Michigan’s public mental health system was administered. I had assumed there was a central state office that had authority over several smaller local branches.
Instead, Michigan’s public mental health is administered through over 46 community mental health service agencies (CMHSP). While some of the smaller county agencies have coordinated together to provide services, they remain independent organizations, structurally and philosophically.
One could argue that more local control can allow the individual CMHSPs to tailor programs and resources to the varied demographics they serve. The counterpoint is that each CMHSP is forced to go it alone with limited resources. My concern is that our system is far too fragmented without a strong central state entity to monitor the local CMHSPs, share best practices and set standards. A patient should receive the same high-level of care whether they live in Detroit or Tawas.
The need for integration
More than 10 years ago, then-Gov. Jennifer Granholm convened the Michigan Mental Health Commission to fix a “broken” system. I took particular notice of one part of its recommendations:
- Provide wide access to patient treatment information while maintaining confidentiality
- Provide medical integration with primary care providers
- Provide continuity of care tracking
I applaud the Commission’s foresight in that non-behavioral health medicine has continued to accomplish these same goals. With most health systems adopting electronic medical records, the time is right for our public mental health system to fully integrate with their physical medicine partners to assure appropriate and efficient care.
In 2013, Gov. Rick Snyder’s Mental Health and Wellness Commission issued a recommendation to “endorse the Michigan Health Information Network efforts to support care-coordination across the boundaries of physical and behavioral health settings.” As reported in Crain’s, there has been progress made in this recommendation.
My concern is that we are not doing enough. Simply having the ability to link a patient’s mental and physical health history may not allow health professionals to make timely interventions. Because of the stigma associated with mental illness and substance abuse, patients are not likely to share this in emergency rooms. One more reason to have a stronger central state entity to help guide this process with the multiple health systems and hospitals in Michigan.
Rethinking long-term inpatient care
Closing psychiatric hospitals in favor of treating more patients in the community (deinstitutionalization) has been the practice for several decades in Michigan and in the rest of the country. The reasons are manifold: the history of abuse of patients in several institutions, the potential for civil rights violations, and the development of new drugs which have given hope that patients could be treated in a community setting.
The number of Michigan’s public health hospitals designed for mental illness and developmental disabilities has decreased to five, with the argument made that we can continue to serve this vulnerable population without a larger number of long-term, inpatient beds. A recent opinion piece in the Journal of the American Medical Association has countered this well-established notion by proposing that we “bring back asylums”. The authors of this article point to the fact that several of the most chronically ill patients are ill-suited to be taken care of in an ambulatory setting and, instead, fill emergency rooms. From my own review at the hospital I work at, I believe the authors are accurate in their claims.
The recommendations I have outlined – creating a stronger state authority, developing better integration between behavioral medicine and physical medicine, and investing in additional inpatient facilities for the chronically ill – will come at a cost, at a time when our locally elected officials appear obsessed with cutting spending. I would argue that without reform and investment, our system will remain inefficient and, thereby, wasteful.