About once a week, an elderly person is stuck in the emergency room with a mental-health problem that went undiagnosed and untreated for too long. Caregivers at home, in assisted living or at the hospital are unable to help, worried about the safety of other staff and residents. But the person might not qualify for an inpatient bed at a psychiatric hospital — or there often can be a wait for a free bed — and there’s nowhere else to go.
“It’s a major challenge we face,” said Heather Finch, interim behavioral health program manager at Memorial Hospital. “But it isn’t a problem unique to this ED. We take good care of them while they’re here, but the emergency department isn’t the place for them for days and days and days.”
Neither hospital in town — Memorial nor Penrose-St. Francis Health Services — is licensed as a psychiatric hospital, so there’s no place for elderly patients to go for long-term mental-health care. The long-term care facility won’t take them back, worrying about safety of residents and staff members. They might not qualify for one of the 32 beds at Peak View Behavioral Health, the city’s only behavioral health hospital that specializes in geriatric psychology — or maybe the hospital is already full. So they remain in the emergency department.
“It’s really not meant to be a place to hold people, to treat them for mental-health disorders,” Finch said. “The emergency department is to stabilize, to treat acute-care patients.”
Elderly people are particularly susceptible to medicines, anesthesia and illnesses that can change their behavior patterns.[/pullquote]
It starts like this: Patients are ignored as they begin showing signs of agitation, depression or delirium — until the problem is so bad they lash out at caregivers, threatening workers, other residents and themselves. At that point, with no other options, caregivers call the police and the elderly resident gets a ride to the emergency room via police escort. Hospital staffers stabilize the scared, disoriented patient, then try to find a place for better psychiatric care. Those patients frequently spend days or weeks at the hospital, in the emergency department.
It’s both expensive and inefficient. And Finch says, incredibly sad.
That scene is replayed nationally in emergency rooms across the nation. But in Colorado Springs, emergency doctors and long-term care nurses are working with mental-health providers at AspenPointe, Cedar Springs and Peak View to find ways to stop patient problems from escalating until the emergency department is the only place to turn.
“We are very fortunate to have so many professionals coming together and saying, ‘We can do better,’” said Melissa DeSutter, director of business development at Peak View. “This is a volunteer group that started with the emergency departments (at Memorial and Penrose) wanting to understand how they could help be a part of the solution. They are trying to be proactive and I truly commend them for working on this. At the end of the day, we want to make sure we’re doing what’s right for the patient.”
Sometimes that’s the emergency department, Finch said, for patients who might have another illness or might be acting out because of disease or medicine. But it’s not the solution.
“I think we have an opportunity now to share from different perspectives, to find a better way that’s more ideal for the patient,” Finch said. “EDs are used heavily; it’s true around the nation. But this group is working to smooth out the process by working together for a solution.”
Confusion among professionals
But what’s right for the patient is often unknown even to health care professionals. There’s confusion about what to do when.
“We always say, ‘Call us as soon as possible,’” said Paula Henry, Peak View director of admissions. “As soon as the behaviors start showing, and before it gets too serious to deter with therapy. That way, we can see what needs to be done. First of all, we have to rule out any sort of medical reason for the behavior, so we’ll need labs and physicals.”
Elderly people are particularly susceptible to medicines, anesthesia and illnesses that can change their behavior patterns. Something as simple as a urinary-tract infection can lead to delirium. Lab tests rule out a medical cause for the behavior.
But even the issue of lab tests and physicals isn’t as easy as it sounds. If a long-term care facility waits too long for lab work, the patient can become uncooperative. Then the only choice could be the emergency room, where doctors can obtain vital tests necessary to check a patient’s physical health. But the idea is to avoid that route whenever possible.
“The goal is to go from A to B — from the long-term care facility to the behavioral health hospital,” Henry said. “Is it possible to avoid the ED?”
Some providers are skeptical. Rules and regulations keep long-term care facilities from offering medicine or giving lab tests without the patient’s specific permission. Sometimes, it can’t be done. And sometimes, it takes too long to get a psychiatrist’s approval.
“That’s why we need the information at the beginning of the episode, before it’s 3 a.m. and people are stressed out and scared,” Henry said. “That’s when we’re in the best position to help. Our psychiatrist needs all the information available to make an informed decision.”
The group says more education is needed for caregivers, psychiatrists and emergency room doctors — and the patients themselves. For the elderly, seeking help for mental illness carries a deep shame and stigma that workers have to overcome.
“People ask me, ‘Does your van have your name on it?’ when we go to pick them up at the facility,” Henry said. “Seniors are the only ones who ever ask that question — they’re embarrassed.”
And because it’s embarrassing, group therapy won’t work.
“Seniors don’t want to talk in front of people who are younger,” Henry said. “They want their own age group, someone who’s seasoned, who knows what they’re going through. So we’ve developed these senior-specific therapy groups. It works really well.”
Peak View has two geriatric units: 16 beds for those struggling from traditional behavioral problems and 16 for Alzheimer’s patients.
“On any given day, we have between 24 and 32 patients between senior inpatient units,” DeSutter said.
When all those beds are full, patients must go to Cedar Springs or as far away as Denver or Pueblo.
“We want to keep patients local,” said Dr. Fred Feinsod, a local geriatrician and chairman of the group. “It’s better for them. So we need to find ways to get them help before they reach a crisis point.”
Educating people to know that help is readily available — Peak View is even working on a mobile unit that will assess residents at local long-term care facilities and assisted-living homes — is the biggest hurdle, DeSutter said.
“I’m not so sure we’re hurting as badly in terms of the number of services we offer as much as we are on people understanding how and where they can access service, how to prevent a mental-health crisis by being proactive as much as possible and also understanding the expectations and limitations around these types of concern,” she said. “There’s confusion even with stakeholders who help people every day.”
Opening lines of communication is the main goal of the mental-health group meeting monthly at Pikes Peak Area Council of Governments.
“The problem isn’t the people in this room,” said one ER doctor. “It’s educating the people who aren’t in this room. People who still have to make the decisions. We need a way to reach them.”