Many North Dakota hospitals shirk mentally ill patients, refuse to serve ‘those people,’ report finds
A consultant's report for a legislative committee said jails still end up taking people in mental health crisis who should be hospitalized — a situation the study compares to Third World countries.
BISMARCK — A consultant has found that North Dakota has enough psychiatric hospital beds to treat the acutely mentally ill but delivered a scathing criticism of many hospitals around the state it said “blatantly” shirk their legal obligation to treat people in mental health crises.
The draft report by Renee Schulte Consulting will be presented Tuesday, April 5, to the North Dakota Legislature’s interim Acute Psychiatric Treatment Committee, which is studying how to fill gaps in the mental health system.
In a finding the consultant acknowledged will surprise many — there have been loud cries from jailers, prosecutors and advocates complaining of the lack of access to psychiatric beds — the report said the number of those beds actually is adequate if the beds are better managed.
“Many are in the wrong locations and shared with out-of-state placements,” the report said, noting most private beds are located in eastern North Dakota near the Minnesota border.
The 36 critical access hospitals in rural communities scattered around the state serve as a health care safety net and will be a critical component — in tandem with telepsychiatric evaluations and consultations — in delivering mental health crisis care, the report said.
“Critical access hospitals across the state must be equipped to assess, stabilize and transfer mental health and substance use patients to appropriate levels of care and not violate federal law," the report said. "The use and reimbursement of telepsychiatry in these hospitals can make it possible promptly.”
The report’s “ballpark estimate” of giving all 36 of North Dakota’s critical access hospitals access to around-the-clock crisis telepsychiatry services ranged from $1.5 million to $2 million per year.
The consultant found a reluctance among rural hospitals to treat mentally ill patients despite their designation as critical access hospitals.
“Rural hospitals often do not want to care for ‘those people,’ as described to us while conducting interviews,” even though they receive federal funding to provide service for “acute care of all types,” the authors wrote.
“Many rural access hospitals across the country have or are in the process of increasing capacity in the provision of behavioral healthcare,” the report said.
However, the report said, "In North Dakota, hospitals are blatantly refusing to treat patients presenting with acute psychiatric issues,” which is a violation of a 1986 federal law for hospitals receiving Medicare payments.
“Across the state, countless reports have been provided of hospitals refusing to admit patients in acute psychiatric crises and coercing community-based providers and/or families to ‘take them back’ even when clinically inappropriate and ill-equipped to manage individuals in need of emergent psychiatric stabilization," the report said.
Tim Blasl, president of the North Dakota Hospital Association, said he found the allegation that some hospitals have refused to care for psychiatric patients surprising, and he said he wants to question the study's authors.
“I’m not aware of any hospital blatantly refusing to treat a patient with an acute psychiatric illness,” he said. “That would be illegal. ... They treat, assess and stabilize every patient that comes through the door.”
However, he added, critical access hospitals lack psychiatric inpatient beds and must transfer patients to urban medical centers. “They are trying to find a bed for that patient somewhere around the state,” Blasl said.
The report also said patient “dumping” was sometimes the fate of mentally ill patients, a problem consultants said could be fixed by contract requirements.
“Across the state, you can hear countless tales of people being rejected by providers,” the report said. “Or, once a person has an acute episode, the provider refuses to take them back after stabilization.”
The practice happens at hospitals, long-term care homes and youth treatment centers, the report said, adding that the problem can be solved with what’s called a “no reject, no eject” policy.
Such a policy means someone who is eligible can’t be denied service or discharged “based on the severity or complexity of that individual’s mental health” and other needs, the report said. Adding that requirement to provider contracts would assure that those with mental health and substance use disorders “will be treated and cared for with a person-centered approach,” the report said.
The policy also would help to take the pressure off the State Hospital because only those with the “highest level of acuity” would require care in the State Hospital, the consultants wrote.
The consultant agreed that North Dakota should replace the aging State Hospital, a complex in Jamestown where half of 28 buildings are recommended for demolition and the newest building dates to the 1980s.
The Schulte report endorsed a determination by another consultant in 2020 that found a new hospital with 75 to 85 beds should be adequate for the state’s needs.
Although North Dakota has 244 adult acute psychiatric beds — more than the 231 deemed optimal for the state’s population — 160 of those beds are available to out-of-state patients, limiting access for North Dakota residents, the report said. Hospitals in Fargo and Grand Forks, for example, serve many Minnesota patients.
Because up to half of North Dakota’s private hospital beds are occupied by non-residents, “this puts North Dakota into a mild to moderate shortage of beds,” even assuming a State Hospital staffed for 75 beds, the report said.
The State Hospital should have a specialized role, serving forensic patients involved in the criminal justice system or complex cases and should no longer provide care for the Jamestown and Devils Lake areas, the consultant recommended.
Less than 8% of North Dakota’s 3,323 hospital beds are capable of treating acute behavioral health conditions in a resident home community, according to the study.
For years an acknowledged problem, jails sometimes have housed the mentally ill because of a lack of mental health crisis services, especially in western North Dakota.
“Based upon direct observation and first-hand interviews the issues around incarcerated persons with psychiatric illness in jails are appalling,” the report said. “The backlog of persons who were held in jail and eventually freed without charges being filed is something to be expected in third world countries, certainly not here. Where is the person’s due process? Where is the right to freedom or least restrictive levels of care?”
Urgent telepsychiatry appointments could be available within 24 hours of a request to serve jail inmates, at an estimated yearly cost of $500,000 to $700,000, according to the report. Psychiatric assessments would be completed by a North Dakota-licensed psychiatrist or psychiatric nurse practitioner. Medications would come from a jail formulary to control costs and avoid abuse.
Policymakers are hampered by a lack of comprehensive mental health data in North Dakota, where information is “siloed.” A comprehensive data system, combining public and private providers and funding information, is needed, the study found.
An audit of the State Hospital and eight regional human service centers “would be one way to start getting objective information on where monies are being spent, on who and for what levels of care,” the report said.
The study recommended the state take over certification and licensure for behavioral health professionals, now left to volunteer boards.
The consultant urged that, after a decade of studies and discussions about how to improve behavioral health care in the state, action is needed.
“North Dakota does not have time to continue to study this issue,” the report said. “Everyone knows the challenges. It is time to act.”
Rep. Jon Nelson, R-Rugby, chairman of the interim study committee, said private health care providers have a critical role to play in mental health care delivery.
“We need some partners in this,” he said. “I don’t see the health care industry stepping up to the level they’ll need to.”
Sen. Tim Mathern, D-Fargo, a member of the committee, said the focus must be on shoring up services that are available in communities throughout the state. The primary focus should not be on a new State Hospital, he said.
“We need to solve those foundational issues, lest we build a building and it’s filled up the second day. We still have the same system, unless the state makes needed changes, Mathern said. “To me, it’s kind of a call to fix the human services system.”
He added: “The report calls for all the hospitals in North Dakota to actively take people, even if it’s only for temporary crisis stabilization. There’s so many people that land in a jail or in a police car on their way to Prairie St. John’s,” a psychiatric hospital in Fargo, “or someplace else.”
A final report will be presented later to the committee, which could draft legislation to present to the 2023 legislative session.