The Evolution of Mental Health Services at Lawrence Memorial Hospital Presented to CHIP Mental...

The Evolution of Mental Health Services at Lawrence Memorial Hospital

Presented to CHIP Mental Health Task Force

June 29, 2005

There have been many aspects of the closure of the inpatient Mental Health Unit at LMH that have been publicly misunderstood. This is a very complex matter. The following information will clarify some of the issues that led to the closure, as well as many remaining issues.

Mental Health Services at LMH

History & Background

The Mental Health Unit at Lawrence Memorial Hospital started in 1973 as a small general psychiatric unit in the “1969 wing”.

Psychiatric treatment in the United States has undergone dramatic shifts in the last several decades, including drastic reduction in inpatient hospitalization.


Patients who are admitted are only in the hospital until stabilization of their condition is achieved, thus dramatically decreasing the length of stay.

With admission only available for acute and serious psychiatric crisis, most patients, including the chronically mentally ill who previously were hospitalized for long periods of time, are treated in the outpatient setting.


In our community, the Bert Nash Community Mental Health Center has developed extensive outpatient programming to meet the changing demands for a growing outpatient population.

Because of the existence of Bert Nash providing outpatient services in the community, LMH has never offered this service and has only offered inpatient mental health care, primarily focused on crisis stabilization.


In January 2001 the Mental Health Unit was a 15-bed general, voluntary adult psychiatric unit primarily serving the population of Douglas County and clients of the Bert Nash Mental Health Center.

The census was usually very low (2000 average daily census was 3.7 patients) and the revenue was problematic.


The hospital considered closing the ailing unit in 2000. After extensive study and review, including dialogue with the Lawrence community, it was decided to continue to care for adult mental health patients and to expand the services to include geriatric mental health patients.

Universal Health Systems Management Services was hired to establish and manage the new unit. The hope was that this would serve the needs of the patients and also enhance the viability of the unit.


In January 2001, Dr. John Whipple was hired by UHS for the development of Geriatric Services and as Medical Director.

Bert Nash continued to admit adult crisis patients and provided three psychiatrists for this purpose: Dr. Rimando, Dr. Whitten-Vile and Dr. Douglas, as well as an ARNP.

Dr. Chediak, an independent practitioner in the community, had active privileges and shared on-call responsibilities so that a total of five psychiatrists rotated call.

At that time a sixth psychiatrist, Dr. Hale, an independent practitioner in the community, went to courtesy staff.


There was a turn-around with these expanded services. There were 504 discharges in 2001 with an average daily census of 6.6, compared to 405 discharges in 2000 with an average daily census of 3.7.

The positive trend continued in 2002 with 623 discharges with an average daily census of 7.9.


In May 2003, Dr. Whitten-Vile and Diane Whitten-Vile, both Bert Nash practitioners, relocated.

In June 2003, Dr. Rimando, a Bert Nash practitioner, resigned from active status for health reasons.

Also in June 2003, Dr. Douglas, the only remaining psychiatrist from Bert Nash, resigned his active status at LMH due to his increased outpatient load.

Dr. Whipple and Chediak were left as the only psychiatrists to admit, follow and perform on-call duties.


Because of a shortage of psychiatrists willing to admit inpatients, LMH Mental Health Unit closed to adult crisis stabilization patients on Sept. 1, 2003.

Geriatric psych patients continued to be the focus. Recruitment of other psychiatrists continued. By year end 2003, low census issues concerned leadership and

unit staff with our ability to deliver quality services. 414 discharges for 2003 with an average daily census of 6.


By March 2004 census issues were increasingly severe. Dr. Chediak, an independent practitioner, resigned from

active status. Proposal was made to close the Geripsych Unit due to low

census and lack of psychiatrist coverage. The program director also resigned.

Decision by the LMH Board to close the unit April 30, 2004 Dr. Whipple resigned from active status. 64 discharges January-April 2004; average daily census 1.3.

Mental Health Services at LMH Today

Psychiatric Consultation Services Team developed to continue to address mental health issues of patients throughout the hospital.

Beginning in May 2004, Dr. Pir Shah, who was employed by LMH, began providing consultation services on a 24/7 on-call basis to all areas.

Full time RN Coordinator available for education and training needs of staff, nurse-to-nurse consultations and to facilitate psychiatric consultations on all medical units.


When a psychiatric issue is identified in an Emergency Department patient after evaluation by the emergency physician, a mental health screen/assessment is completed.

Screening is done by LMH social workers or Bert Nash social workers. Bert Nash is required by Kansas law to perform all Medicaid and involuntary mental health screens.

The screener collaborates on a plan for future care with the emergency physician.


If the patient requires inpatient psychiatric hospitalization, an appropriate facility is located. This is determined by personal choice, availability of beds, and voluntary/involuntary status.

If voluntary inpatient care is required, a secure transport service provides transportation. LMH absorbs this cost.

If involuntary inpatient care is required, local law enforcement provides transportation at their cost.


If emergency inpatient psychiatric hospitalization is not required, the patient is stabilized and a discharge plan for outpatient care is developed.

This could include referral to Bert Nash Mental Health Center or private providers per patient choice and acceptance.

Mental Health Services at LMH Tomorrow

In April 2005, the LMH Board approved a plan to enhance Crisis Stabilization Services in the Emergency Department.

The enhanced service will include dedicated physical space in the Emergency Department for two patient beds.

There will be additional staffing dedicated to caring for psychiatric emergency patients.

The new space will provide increased privacy and safety for all patients.

The current processes addressing the needs of emergency patients with mental health issues remain the same.

Mental Health Services at LMH Tomorrow

Construction has begun and is expected to be completed in August 2005. Construction costs are estimated at $150,000.

The Crisis Stabilization Service is expected to serve about 400 patients. LMH estimates is will subsidize the unit at about $1.5 million during the first five years of operation.

This service, according to our research, is unique to our region. Most Emergency Departments address psychiatric patients much as we do today.

Perceptions & Facts Regarding Mental Health Services at LMH

PERCEPTION: The unit was closed for financial reasons.

FACT: When the unit operated as an adult, voluntary unit and additionally served the geriatric population, the unit was close to breaking even. Even when Medicare reimbursement changed in 2004, Lawrence Memorial Hospital was prepared to serve that population had the local psychiatrists remained committed to inpatient care. Previous to 2001, losses were routinely in excess of $300,000 annually.


PERCEPTION: The “market” for this service is significant.

FACT: 538 Douglas County residents received inpatient care somewhere in 2003 for the diagnostic category of Mental Diseases & Disorders. That number is for an entire population of needs including child, adolescent, adult, geriatric and both voluntary and involuntary admissions.

Of those, 335 were served at LMH (January-September 2003). Many psychiatric patients choose to be hospitalized away from their local community.


Operating a quality inpatient unit requires significant staff in addition to psychiatrists. Serving a small group of patients does not lend itself to job satisfaction in order to retain the caliber of staff LMH requires.

Simply put, the market and our ability to serve that market in a quality fashion has not been possible due to a very low census level.


PERCEPTION: The only option for area residents requiring inpatient care is Osawatomie.

FACT: Osawatomie State Hospital does serve area residents, primarily the involuntary population, but other referral centers do exist. Data indicates patient transfers from our Emergency Department during the past year for inpatient care have gone to Stormont-Vail West, Shawnee Mission Medical Center, KU Medical Center, Cushing Hospital in Leavenworth and Osawatomie, to name the most common centers.


Shawnee Mission Medical Center has expanded their inpatient mental health services. They serve adults with psychiatric and addiction needs.

Stormont Vail in Topeka provides adult, child and geriatric psychiatric care.

We have met with both of them to improve how we can work together to serve our community’s needs.


PERCEPTION: LMH does not serve the mental health population today.

FACT: In 2004 the LMH Emergency Department saw nearly 900 patients with some diagnosis related to mental health. Of that number, 567 were discharged to home following a thorough evaluation by the Emergency Physician and, if warranted, a mental health screener. The remaining 333 were transferred to an inpatient unit for voluntary and involuntary admissions.


LMH continues to play a vital role in serving our community’s mental health needs. We employ a psychiatrist, Dr. Pir Shah, a registered psychiatric nurse, Paula Dupigny-Leigh, and several social workers to serve a significant population of LMH inpatients who have a related mental health diagnosis, in addition to other diagnoses. This service is subsidized by LMH on an average of $11,300 a month.


PERCEPTION: LMH and Bert Nash do not work together on this issue.

FACT: Bert Nash provides mental health screening services

to primarily Medicaid patients presenting in our Emergency Department.

LMH reimburses Bert Nash for their screening service for the non-Medicaid patients. This is not always done throughout Kansas where some Community Mental Health Centers provide these services at no charge to local hospitals.

Questions & Answers AboutMental Health Services at LMH

Why doesn’t Bert Nash or LMH just hire psychiatrists to do inpatient care?

Both Bert Nash and LMH routinely employ physicians to serve the community. The issue is that the psychiatrists who have been recruited recently to Lawrence have not wanted to do inpatient care. This leaves the ones who are willing a disproportionately higher level of call which affects lifestyle and office practices negatively.

Reimbursement to physicians for inpatient psychiatric care is extremely low; in fact, some physicians report it costs more to bill for the services than the reimbursement they receive.


There must be a demonstrated community need to justify the recruitment/employment of physicians.

LMH uses a demand analysis study to determine potential physician demand based on our community’s demographics versus current and projected physician supply.

Projecting ahead to 2008, the number of psychiatrists needed to serve Douglas County is 5.34. According to the Board of Healing Arts, currently the community has 13 psychiatrists. (Note: these 13 may not all practice full-time in Lawrence. Of that number, 5 are currently on some category of the LMH Medical Staff.)


What does it take to recruit a psychiatrist?

Assuming a mid-range salary of $160,000 plus $32,000 for benefits creates an annual cost of $192,000 plus overhead expenses normally associated with a practice.

These costs would have to be offset by revenues generated by the psychiatrist’s practice or subsidized from another source.

For coverage on an inpatient unit, 3 full-time psychiatrists would be necessary for a 24/7 365-day service.


If all other issues were solved, why doesn’t LMH just open up some beds for this service?

The area that previously housed the inpatient unit is in the 1969 wing of the hospital. This wing, because of numerous structural and facility issues, is scheduled to be demolished in September 2005.


So why don’t you use other beds in the hospital? The specialized facility requirements for inpatient psychiatric

care dictate safety and security measures not commonly found on most hospital inpatient units. Additionally, to adequately serve the needs of these patients, state licensure requirements dictate a variety of additional facilities such as group treatment rooms, recreational space and other requirements. LMH does not have the space for this currently.


LMH has announced plans to enlarge its facility. Why can’t you just include the space needs in that expansion?

LMH has limits on our ability to finance a major expansion. The proposed expansion is being designed to serve the greatest number of our community’s needs in the highest quality fashion.

Summary

LMH does serve psychiatric emergency patients with crisis stabilization services and is currently enhancing the service with physical renovations and additional staffing.

LMH serves inpatients with psychiatric consultation services. LMH does have relationships with regional providers for

inpatient psychiatric care. LMH provides secure transportation for voluntary inpatient

transfers. Opportunities to improve relationship with Bert Nash. Opportunities to communicate existing services to area

providers. Opportunities to educate community and the nation about

mental health issues.

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