Sharon Pendlebury of Cheyenne Regional Medical Center’s Behavioral Health Services poses at her facility.
By Tom Lacock
Wyoming Medical Society
More and more clients seek mental health services, which means the costs to the state also increase. However, finding two people who agree on the reasons is difficult and makes finding solutions just as hard.
“I wish we could answer that,” says Richard Dunkley, superintendent of the Wyoming State Hospital. “There were a lot of hypotheses on what is going on and why we are seeing an increase. I’m not sure anyone knows for sure.”
A brief survey of the increase of mental health clients served provokes concern. The Wyoming State Hospital (WSH) has experienced a sharp rise in the number of involuntary hospitalizations from 208 in 2012 to 341 last year. WSH estimates 368 involuntary hospitalizations by the end of 2016. Peak Wellness of Cheyenne, a community mental health center operating in the state’s southeast corner, says it served 5,558 clients in 2015. As of April 11, Peak has seen 5,112 clients already, and estimates it will see nearly 6,134 in 2016.
Just as troubling, the Cowboy State averages 20.5 suicides per capita — the fifth-highest rate in the nation, a full seven points higher than the national average and the sixth highest cause of death in the state. On a positive note, those numbers are down from a high of 29.6 suicides per capita in Wyoming in 2012.
Terresa Humphries-Wadsworth, PhD, is the Director of Statewide Suicide Prevention for the Prevention Management Organization of Wyoming. Her organization contracts with the Wyoming Department of Health to consider factors for the increased numbers of substance abuse, as well as methods for reducing the suicide rate. She agrees the numbers are going up, but she also believes it is a bubble which will burst in two or three years. Humphries-Wadsworth cited a recent study in Wyoming that indicates the stigma surrounding mental health treatment is melting away and points out nearly 40,000 Wyomingites have been trained in suicide prevention recognition and response, which is helping Wyomingites to seek treatment sooner than in the past. However, that is creating a stress on a small community of mental health providers.
“The entire state continues to (have) health care shortage areas for mental health care,” Humphries-Wadsworth says. “It is still a steep curve, but I see the light where we will see the numbers coming down in terms of suicide attempts, involuntary hospitalization and the negative consequences from substance abuse.”
She says the positives to come out of the bubble of increased mental health needs includes integration of mental health in primary care settings and and crisis intervention training with law enforcement. Other areas are looking to more mid-level providers to help with mental health treatments and mental health extenders, who aren’t licensed, but can work under the supervision of a provider who is licensed.
One question surrounding the increased mental health numbers in Wyoming is whether it is possible to have a conversation about mental health without discussing substance abuse. Dunkley says those two pieces are difficult to separate, pointing out that a study at the State Hospital notes, 60 percent of civil committals last year had co-occurring diagnosis. Peak Wellness Center says 24 percent of its clients are being treated for substance abuse alone while a large number are also being treated for co-occurring diagnoses.
“They are really integrated,” says Humphries-Wadsworth. “Statistically, of people who die by suicide, a significant portion had mental health problems, according to SAMHSA, that is between 80 to 90 percent. The percentage of those with a substance abuse problem, is between 30-40 percent.”
Peak offers, among other services, primary residential treatment for substance dependence, dual diagnosis, and detox centers for men and women. Peak’s Annual Report says last year it treated 635 clients with residential services. Linda Goodman, the Chief Clinical Officer at Peak says her group could fill another 44 residential treatment beds in the southeast part of the state. The best case scenario would have those beds in a setting where women could also bring their children to treatment.
“We need to let women get care for substance abuse disorder and to do that without having to leave their kids,” Goodman says. “Their kids need treatment as well to deal with the ramifications of living in a household that has that level of disruption.”
If you are in Cheyenne Regional Medical Center’s Behavioral Health Services Division (BHS) chances are you are in rough shape. Sharon Pendlebury, is the administrator, and reports that in order to be placed in a bed in BHS, “you have to be very unwell.” Pendlebury came to Cheyenne after stints in the SCL Health System, as well as facilities in Greeley and Longmont. Prior to her time in Colorado, she worked in England with clients who had criminal backgrounds and were struggling with integrating into their communities.
“We do a good job. Our readmission rate was zero percent in the last 30 days,” she says. “The national average is 54 percent and a five-state regional average is 48 percent.”
BHS has 16 beds which remain full (an average of 15.2 full beds per day at BHS). These do not dedicate any of those beds to adolescent, child, or seniors. BHS beds are saved for those who are suicidal, homicidal or gravely disabled. The demand for beds resulted in CRMC conducting a feasibility study which recommended BHS expand to 28 adult beds, 16 senior beds and 10 child beds.
Currently, children are sent to Wyoming Behavioral Institute in Casper, or Mountain Crest or Centennial Peaks in Colorado. Unfortunately, there are no senior beds in Wyoming. In Cheyenne seniors are referred to medical floors. The Wyoming State Facilities Task Force is also working on ways to free up beds at the Wyoming State Hospital by moving long-term residents to the Wyoming Life Resource Center in Lander. Goodman says the state has a need for geriatric psych homes, pointing out someone with a serious mental illness traditionally lives an average of 30 years less than any other adults. Because the quality of healthcare, and the quality of mental healthcare has increased, those with mental illness are living longer than ever. Therefore, we need a gero-psych–specific setting.
“There are many more seniors coming,” Pendlebury says. “We really need to be able to admit seniors with cognitive mental issues and underlying medical needs to an acute senior care unit which has the ability to handle geriatric-psychiatric concerns, as well as what we already have in place.”
In Cheyenne, BHS partners with Peak Wellness Center, the Community Mental Health Center in the southeast corner of the state. While BHS serves those who are suicidal, homicidal or gravely disabled, Peak compliments BHS by serving those who need help but who do not require hospitalization.
According to its 2015 Annual Report, Peak has offices in Albany, Laramie, Platte, and Goshen Counties and has around a $17.3 million budget, of which state revenues account for 67 percent and Medicaid another 17 percent. Peak served 5,558 patients in 2015 with over 139,180 hours of service. Of that number, 87 percent are adult mental health and substance disorder services. Karl Cline, the new executive director at Peak, holds a Master’s in Psychology, and an MBA. He is the past director for Northeastern Colorado’s Access Behavioral Care in Aurora.
The numbers of people seeking services are going up,” Cline says. “Unemployment may be attributing to this as we are in an economic downturn. We strive to be able to coach our clients through these tough times, but traditional mental health has not been good at that. I want to change that.”
Cline is still in his first year as CEO of Peak and says his vision is to develop more group homes and help others see that we tend to give severely and persistently mentally ill the leftovers of things such as housing, and jobs. He says in a perfect world he would seek the best opportunities for Peak clients to be on equal standing for recovery, resilience, employment, and community integration. He says he wants to think about services in a different way keeping the treatment more local.
“I want to think about bigger and better and beyond,” Cline says. “I don’t want to think about little institutions like we have had before. People who get better, get better because they are more local, because the staff who are working with them believe they can recover and be resilient. When clients are independent, they disengage from us. And if a need arises that they come back to seek further services, we view that as success and celebrate it. The reason it is success is because it it progress. That’s great!.”
Finding money to help this population is another hurdle. Few who are in crisis beds are able to continue working or pay for their stay. A BHS study of its involuntary hospitalizations shows 50 percent had a payer source, while a quarter have no payer source and another 15 percent have Medicaid which does not provide reimbursement for involuntary hospitalization. That has led to $797,974 in uncompensated cost for this population. Pendlebury admits mental health is not like vascular surgery, but she says if done right, it can break even and be financially sustainable for a facility like CRMC.
“If you admit people who need to be admitted and find alternative support for those who don’;, if you detain people who need to be detained and absolutely avoid detaining people who don’t need detained; if you work closely with payer sources and the networks with Medicaid, Medicare and really do your very best to make sure people have access to the benefits they need, to support their needs, can you make money? Oh yeah,” she says.
Among the more innovative efforts by BHS is a four-bed mental health pod in the emergency department of Cheyenne Regional Medical Center. The pod has 24-hour coverage from clinical social workers and a team led by Dan Robinson, a PhD.-level neuropsychologist performs assessments (140 last year) directly in the ED when requested. The quick assessments allow Robinson’s team to offer a working diagnosis immediately as well as recommendations for treatment. Inpatient therapists visit the pod daily and a telehealth link allows patients to begin program therapy immediately. BHS is also offering outreach to 11 telehealth sites around the state, including psychiatric outreach into skilled nursing homes.
Cheyenne Regional’s Wyoming Institute of Population Health has produced an accountable community health assessment.. In that document, key drivers are identified related to community health needs, what could work, and how to measure progress. It also outlines partners such as Peak, the VA, The Wyoming Department of Health, and The Cheyenne Regional Medical Group. It suggests everything from more beds, to step-down facilities and in-house crisis intervention teams.
“There are a lot of other things to do with a physician license. If you are going to decide to support this population, the least you can do is be the best,” Pendlebury says.
Cline says he is challenging the status quo in his first year on the job at Peak. He said he hopes to run Peak with more of a recovery model than an institution model. Peak is also trying to work on more integrated care with primary care physicians so a referral isn’t just a business card with little follow-up.
“It’s more about helping people see that recovery is possible. It is okay to teach you and coach you that you are a valuable part of this community, not just a client,” Cline says. “If people could begin to understand this is a problem like any other problem that I have, whether it is depression or diabetes, and I need to get treatment.”