Rural North Dakota hospitals struggle to care for patients in mental health crisis, officials say

BISMARCK — Human services officials sent a woman who was acutely mentally ill and homicidal to Unity Medical Center in Grafton. She spoke of plotting a shooting spree at a local business she had targeted for its lack of exits.

But there was a problem with the referral: Unity Medical Center, a rural critical access hospital, has no psychiatrists, clinical psychologists or other mental health professionals trained to handle such a complex case.

The woman remained in Unity's emergency department while the lightly staffed hospital team spent hours faxing paperwork to other hospitals in the region, desperately trying to find a psychiatric bed where she could be treated.

“I’m not trained to take care of a critically mentally ill patient,” Dr. Matthew Viscito, a family practice physician and Unity’s chief medical officer, told legislators on Wednesday, June 15. His role, he said, should be limited to determining whether there was a physical condition that could explain her unstable mental state.

Viscito’s testimony was given before the North Dakota Legislature’s Acute Psychiatric Treatment Committee, which will draft proposals for addressing the state’s acknowledged crisis in mental health care.

Ultimately, after 15 hours, Unity found a psychiatric bed, Viscito said. “We’ve held patients for days, fortunately rarely,” he said.

Courtesy of Unity Medical Center, Grafton, N.D.

Viscito’s testimony underscores the challenges legislators and human services officials face as they work to enable North Dakota’s 36 critical access hospitals to help fill gaps in crisis mental health services in rural areas, considered one of the most pressing needs.

Jac McTaggart, an executive with Sanford Health hospitals in Hillsboro and Mayville, estimated it would cost $100,000 per bed to convert a standard medical-surgical room to one that could safely care for someone with an acute mental illness.

But the real problem, he said, is the dire shortage of nurses and other health professionals.

Sanford Medical Center in Hillsboro has been short two registered nurses for nine months and has relied on expensive temporary nurses, McTaggart said.

Sen. Tim Mathern, D-Fargo, asked McTaggart, “If we gave you the $100,000, would you do it?”

“Not without my staff,” McTaggart replied.

Rep. Jon Nelson, R-Rugby, the interim committee’s chairman, said in his view the goal was to call upon critical access hospitals to stabilize acutely mentally ill patients, not to provide inpatient psychiatric services.

Both McTaggart and Viscito rebutted allegations raised by the consultant’s report that rural hospitals were “dumping” mentally ill patients.

“These patients aren’t dumped by us,” Viscito said. “They are dumped on us.”

Unless ordered into treatment by a judge, patients can refuse treatment, which sometimes might be portrayed as dumping, McTaggart said.

The committee, which received many recommendations for expanded telehealth services to make care available in rural areas, heard from Integrated Telehealth Partners, a firm that provides mental health evaluations and follow-up services for emergency departments in 65 Iowa hospitals, including 59 critical access hospitals.

The average response time is 68 minutes, and the average length of an evaluation is 47 minutes, Doug Wilson, the firm’s founder and president, told legislators.

When Integrated Telehealth Partners started, 70% of mental health patients presenting in emergency rooms were hospitalized, a rate that dropped below 50% when the firm began working with hospitals, he said.

The firm also provides services to jails. North Dakota jails large and small struggle to deal with inmates who have untreated mental illness, the committee has been told.

Integrated Telehealth Partners provides psychiatric services to jails, with appointments available seven days a week and new appointments within three days. Urgent appointments are available 24 hours a day, seven days a week, Wilson said.

Multiple studies have shown, he said, that telehealth psychiatric services yield results that are equivalent to face-to-face care.

Pamela Sagness, director of behavioral health for the North Dakota Department of Human Services, presented the committee with a list of proposals in response to recommendations in a report by Renee Schulte Consulting, which evaluated the state’s behavioral health services for the committee.

Those proposals include supporting:

• A new State Hospital in Jamestown with 75 to 85 beds and a revised mission for the State Hospital, which no longer would provide psychiatric services for Jamestown and Devils Lake. Instead, the state would seek local partners to assume that role.
• Residential substance abuse care outside the State Hospital.
• Money to demolish buildings no longer needed on the campus of the State Hospital.
• Expanding substance use disorder treatment in rural areas.
• Expanding crisis stabilization services, including getting electronic tablets to jails for telehealth consultations to care for mentally ill inmates.
• Greater financial accountability and budgetary transparency so officials can better understand how effectively funding for behavioral health care is being spent.
• Reducing behavioral health care workforce barriers.

Sen. Kathy Hogan, D-Fargo, said refining the State Hospital’s mission will be important in designing the new hospital. Fundamental questions should be answered, including, “Do we really want a children’s unit at the State Hospital?”
Nelson said behavioral health services for adolescents are a priority. “We’re aware of the gap in adolescent services,” he said. “That’s something we need to do sooner rather than later.”

Talk about the new State Hospital should not overshadow the need for expanded programs, Mathern said, prompting agreement from Sagness.

“I bring up preventive and early intervention all the time,” she said. “We need to continue to invest earlier.”