(formerly called Long-Term Acute Care Psychiatric Capacity Team ) As of October 15, 2010

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1 MPC REGIONAL PSYCHIATRIC CAPACITY ANALYSIS AND RECOMMENDATIONS Approved by RHC (October 20, 2010) and its Regional Psychiatric Capacity Team (October 8, 2010) (formerly called Long-Term Acute Care Psychiatric Capacity Team ) I. SUMMARY OF KEY FINDINGS As of October 15, The Eastern Region of Missouri has experienced an 817-bed decrease (-42%) in acute care psychiatric beds over the past 20 years and an 89-bed decrease (-10%) since If these trends continue, the Eastern Region will experience a shortage of acute care psychiatric beds in the near future. 2. In 2009, on an average day, approximately 75 acute psychiatric beds were open in the Eastern Region apart from the 50 beds being closed by the State of MO at St. Louis Metropolitan Psychiatric Center(MPC) and beds operated by the Veterans Administration. Additional closure of psychiatric beds in the Eastern Region may trigger significant bed shortages in the Eastern Region in the future. The types of populations served and the geography of these beds are important considerations if and as future reductions occur. 3. The community behavioral health system in the Eastern Region continues to have significant capacity constraints, and serves less than one-half of those in need of services. Analysis completed by RHC in 2006 conservatively estimated that an additional $87 million would be needed annually to provide adequate community behavioral health services to the adult safety net population in the Eastern region. Studies show that investment in intensive community behavioral health services can reduce the number of inpatient psychiatric days and psych Emergency Department (ED) visits in the Eastern Region. 4. The development of psychiatric acute access center/ brief treatment unit also will help to address the short-term acute crisis regarding the closure of MPC inpatient beds and ED and position the region to respond if additional psychiatric inpatient beds are lost in the future. Without these solutions, continued bottlenecks likely will occur in regional EDs. 5. Demand exists for one psychiatric acute access center/ brief treatment unit in the Eastern Region, with approximately 30 individuals potentially utilizing this service daily. However, it is unclear if demand will support additional satellite units. The current MPC location is ideal for the stabilization unit given potential demand patterns. Until experience is gained with actual 1

2 volumes to an initial center at MPC, the RPC Task Force recommends only one such unit begin operations in EMS providers and law enforcement personnel should be immediately contacted to ensure proper protocols and Memorandums of Understanding (MOUs) are established for referral to this center. 7. While additional modeling of services and costs is necessary, it is anticipated that an annual subsidy will be required to operate the psychiatric acute access center/observation unit, given initial revenue and cost models. Given the importance of these services to patients and families in the region, the RPC Task Force recommends that a broad community consortium that includes the State of MO and community hospitals annually invest the resources needed for the unit to break even. 8. The RPC Task Force also recommends the following: 9. The State should work with the Missouri Hospital Association (MHA) to create an Eastern Region Hospital Collaboration Agreement for psychiatric services. Included in this agreement will be protocols for the transfer of patients evaluated in the psychiatric acute access center/ brief treatment unit and determined to need inpatient medical care, as well as a protocol for equitable participation by hospitals in court-ordered involuntary hospital admissions. Public and routine reporting from the psychiatric acute access center/ brief treatment unit will also be essential. 10. The State, MHA, and the Behavioral Health Network (BHN) should collaborate to assess the utilization of Eastern Region psychiatric beds by providers and courts outside of the St. Louis region. If applicable, the State and MHA should develop statewide protocols for the equitable referral of psychiatric patients to St. Louis providers given current capacity constraints in the Eastern Region. 11. The BHN, State of MO, and Eastern Region providers and community members should continue implementation of the region s 2006 and 2009 blueprint for transforming behavioral health services, with priority to those recommendations that will directly assist the region in light of the recent closure of services at MPC. 12. The State of MO and BHN should report regional access metrics for behavioral health services on an ongoing basis. As part of this regional reporting, MHA & community hospitals should track and publically report psychiatric ED volumes on a periodic basis. 13. The BHN board of directors should revisit the current BHN by-laws to address the underrepresentation of the hospital community on the board of this organization. 2

3 II. BACKGROUND In April 2010, the State of Missouri Department of Mental Health (DMH) announced its intent to close the Emergency Department (ED) and acute care beds at Metropolitan St. Louis Psychiatric Center (MPC). On May 19, 2010, DMH made a formal request to the St. Louis Regional Health Commission (RHC) to create a local plan to address issues created by the closure. In response to DMH s request and with the generous support of the Missouri Foundation for Health (MFH), RHC convened a planning process to address issues concerning this closure, as follows: Planning Team Structure The Short-Term Crisis Management Team and MPC Planning Group began meeting in May 2010, and submitted an Impact Statement and Emergency Response Plan to the State on August 16, 2010, which are available on the RHC s website at These teams addressed immediate, shortterm issues related to the closure of services at MPC. However, the teams were not able to address issues of long-term capacity or mid-range solutions to potential capacity issues in the Eastern Region given the short window of planning time afforded these teams prior to the closure of ED and acute services at MPC on July 15, With the completion of the Short-Term Crisis Management Team deliverables in August 2010, the RHC convened a Regional Psychiatric Capacity Task Force to develop 3

4 additional analysis and longer-term solutions for the closure of services at MPC than was possible in the initial days surrounding the closure of MPC service in mid-july. The charge of the Regional Psychiatric Capacity (RPC) Task Force as funded and approved by MFH is to: Create an analysis of acute psychiatric care capacity in St. Louis region, taking into account the removal of MPC beds from regional services, and Develop recommendations to the State of Missouri, Department of Mental Health, and regional psychiatric health care providers and organizations, to address the issues identified in these assessments. The RPC team began meeting in August 2010, with final deliverables due by the end of October The roster of the RPC team is attached as Appendix A to this document. This report summarizes the work and discussions of this Regional Psychiatric Capacity (RPC) Team. The meetings of the RPC Team were open to the public, and each meeting had active participation by non-team members in attendance. In addition, the MPC Planning Group continued meeting in August, September, and October, and had extensive input into this document. The St. Louis Regional Health Commission approved this document on October 20, The RPC team process has been conducted in two phases: (1) psychiatric capacity analysis; (2) recommendation development. One of the proposed recommendations of the Short-term Crisis Management Team was the creation of stabilization unit(s) or services to improve regional capacity to treat those suffering an acute psychiatric or substance abuse issue requiring immediate and urgent medical attention. Several members of the Short-Term Crisis Management Team, the MPC Planning Group, and the Commission believe this recommendation to be especially important in light of the elimination of psychiatric emergency services at MPC. Given this discussion, the RPC team spent considerable time providing additional detail to this recommendation to assess whether the State, local health care organizations, and others may wish to fund the start-up of these services in the near term. The planning documents completed by the RPC team on the concept of the psychiatric stabilization model have been included for public consideration in this report. This model is comprised of two types of facilities: an acute Access Center, and a psychiatric observation unit(s), that are described later in this report. As such, this report is organized into three main sections: (1) Capacity Analysis; (2) Recommendations; and (3) Detail re: Regional Psychiatric Stabilization Model recommendation, as follows: 4

5 III. REGIONAL PSYCHIATRIC CAPACITY ANALYSIS A. Review of Key Findings re: MPC from previous Impact Statement On August 16, 2010, the RHC s MPC Short-Term Crisis Management Team submitted an Impact Statement concerning the July 2010 closure of services at MPC. Key findings from this analysis include: 1. Since 2006, MPC has been at 100 beds or fewer. Over the last several years, this number has steadily declined. Since December 2009, MPC has been operating at 50 beds. This decline has reduced the annualized discharges from about 1,500 in fiscal year 2009 to about 1,200 for the fiscal year The MPC ED also has experienced declining volumes. The ED treated about 4,000 patients in fiscal year 2009, down to an annualized 2,800 patients for fiscal year Exhibit #1 - Fiscal Year 2010 MPC ED Visits Non-Admissions Admissions Total July August September October November December January February March April May Source: State of MO Department of Mental Health 3. These recent numbers represent an average of about 7-8 patient visits per day at MPC s emergency department, resulting in 2-3 inpatient admissions per day. While these numbers are averages, it is important to note that the emergency department can reach up to 17 visits per day with peak capacity Monday through Friday from 10 a.m. 8 p.m. 5

6 B. Eastern Region Psychiatric (Psych) Bed Capacity a. Psych Bed Trends ( ) Steady Decline in Regional Capacity In 1990, the Eastern Region had 1,955 acute care beds dedicated to psychiatric (psych) care, according to data provided to RHC by the State of Missouri, Department of Mental Health. By 2010, this number had declined to 1,138, or a 42% decrease over the 20 year period. In 1990, the community hospitals in the Eastern Region operated 1,432 acute psych beds, the State of MO operated 388 beds, and the Federal government operated 135 beds through the Veterans Administration. In 2010, these numbers has declined to 778 acute psych beds operated by community hospitals (a 46% decline), 290 operated by the State of MO (a 25% decline), and 70 beds operated by the VA (a 48% decline), as shown on the following graph: Exhibit #2: Eastern Region Acute Care Psychiatric Bed Trends Source: Missouri Department of Mental Health 6

7 b. Current Eastern Region Psychiatric Bed Capacity (2009) The State of MO, Department of Mental Health also provided data concerning total bed capacity by hospital in the Eastern Region in 2009, the most recent available data. Hospital representatives of the RPC Task Force then confirmed the information in this report with data from the Missouri Hospital Industry Data Institute (HIDI), a data set collected by Missouri hospitals available to members of the Missouri Hospital Association (MHA). It is important to note that due to operational issues such as the time needed to manage bed turnover and assignment, infectious disease management, and variation in demand patterns, the hospital industry considers an 85% occupancy rate as maximum capacity. In 2009, 3 of the 13 hospital facilities that currently operate acute psychiatric beds in the Eastern Region operated at or above the 85% occupancy benchmark for psychiatric beds, as illustrated below: Exhibit #3: Eastern Region Acute Care Beds, Psychiatric Beds and Occupancy Rates, 2009 % of Total Beds in Region % of Total Psych Beds in Region % Psych Beds vs. Other Beds in that Hospital 2009 Hospitals - all beds City Total Psych Staff Beds Percent Occupied Total Beds in Hospital Barnes-Jewish Hospital St. Louis City 46 74% 1,258 17% 6% 4% St. John's Mercy Medical Center St. Louis County 72 86% % 9% 7% St. Anthony's Medical Center St. Louis County 74 66% 568 8% 9% 13% St. Luke's Hospital Chesterfield 0 N/A 551 7% 0% 0% SSM DePaul Health Center Bridgeton 99 81% 476 6% 13% 21% SSM St. Mary's Health Center Richmond Heights 35 90% 446 6% 4% 8% Missouri Baptist Medical Center St. Louis County 0 N/A 434 6% 0% 0% Saint Louis University Hospital St. Louis City 40 58% 332 4% 5% 12% SSM St. Joseph Health Center St. Charles 92 81% 331 4% 12% 28% Christian Hospital St. Louis County 40 67% 256 3% 5% 16% St. Louis Children's Hospital St. Louis City 0 N/A 250 3% 0% 0% Jefferson Regional Medical Center Festus 42 66% 192 3% 5% 22% Forest Park Community Hospital St. Louis City 42 72% 178 2% 5% 24% SSM Cardinal Glennon Children's Hospital St. Louis City 0 N/A 176 2% 0% 0% St. Alexius Hospital Broadway/Jefferson St. Louis City 91 70% 169 2% 12% 54% SSM St. Clare Health Center Fenton 0 N/A 158 2% 0% 0% Des Peres Hospital St. Louis County 0 N/A 142 2% 0% 0% SSM St. Joseph Hospital West Lake St. Louis 0 N/A 126 2% 0% 0% Barnes-Jewish St. Peters Hospital St. Peters 0 N/A 110 1% 0% 0% CenterPointe Hospital St. Charles 84 77% 84 1% 11% 100% Barnes-Jewish West County Hospital St. Louis County 0 N/A 84 1% 0% 0% Hawthorn Children's Psychiatric St. Louis County 28 86% 52 1% 4% 54% Progress West HealthCare Center O Fallon 0 N/A 42 1% 0% 0% Shriners Hospitals for Children St. Louis County 0 N/A 42 1% 0% 0% Total 785 7, % 100% 11% Source: Missouri Department of Mental Health; verified by Hospital representatives to the RPC Task Force 7

8 Based on this 2009 data, 75 psych beds would have been open on an average day in the Eastern Region post-mpc closure if all operated at a 85% maximum capacity level, as follows: Exhibit #4 Available Psych Bed Capacity Eastern Region 2009 (@ 85% capacity) Average # of Occupied Beds per Day Number of 85% Capacity Available Capacity per Day: Hospitals - all beds City Total Psych Staff Beds Percent Occupied Barnes-Jewish Hospital St. Louis City 46 74% St. John's Mercy Medical Center St. Louis County 72 86% St. Anthony's Medical Center St. Louis County 74 66% St. Luke's Hospital Chesterfield 0 N/A - - SSM DePaul Health Center Bridgeton 99 81% SSM St. Mary's Health Center Richmond Heights 35 90% Missouri Baptist Medical Center St. Louis County 0 N/A - - Saint Louis University Hospital St. Louis City 40 58% SSM St. Joseph Health Center St. Charles 92 81% Christian Hospital St. Louis County 40 67% St. Louis Children's Hospital St. Louis City 0 N/A - Jefferson Regional Medical Center Festus 42 66% Forest Park Community Hospital St. Louis City 42 72% SSM Cardinal Glennon Children's Hospital St. Louis City 0 N/A - - St. Alexius Hospital Broadway/Jefferson St. Louis City 91 70% SSM St. Clare Health Center Fenton 0 N/A - - Des Peres Hospital St. Louis County 0 N/A - - SSM St. Joseph Hospital West Lake St. Louis 0 N/A - - Barnes-Jewish St. Peters Hospital St. Peters 0 N/A - - CenterPointe Hospital St. Charles 84 77% Barnes-Jewish West County Hospital St. Louis County 0 N/A - - Hawthorn Children's Psychiatric St. Louis County 28 86% Progress West HealthCare Center O Fallon 0 N/A - - Shriners Hospitals for Children St. Louis County 0 N/A Total Source: Missouri Department of Mental Health; verified by Hospital representatives to the RPC Task Force In addition to the 785 psychiatric acute care beds operated in the Eastern Region listed above, the Veterans Administration (VA) also operates an additional 70 psych beds at an average 54% occupancy rate (2009). If these beds were utilized at an 85% capacity rate, an additional beds would have been open on an average day in However, as these beds are reserved for veterans, the RPC Task Force members excluded this capacity from the above analysis, as it is currently difficult to rapidly identify and transfer a VA beneficiary from a community ED setting to the VA psych units. RPC Task Force members believe further discussion with the VA Hospital re: the protocols for admitting onto the VA psych unit may be warranted in the future, especially given the comparatively low occupancy rate of 54% reported in Community hospitals report that a shortage of psych beds have occurred at times of peak usage in the Eastern region (e.g. holidays, times of high community stress), which may occur more frequently if additional psych beds are closed in the future. 8

9 c. Eastern Region Beds by Population Type and Geography (2010) DMH also provided data concerning the number of psychiatric beds in the Eastern Region by population type (adult, geriatric, and child/adolescent) for each hospital with acute psychiatric beds in the Eastern Region updated as of April2010, and compared to 2007, as follows: Exhibit #5: Eastern Region Acute Psych Bed Counts by Type (2007 and 2010) Hospital Location Beds Update 2007 Change from 2007 Adult Geriatric A+G Child/Adol Total Total SSM DePaul Health Center Bridgeton Jefferson Memorial Hospital Crystal City SSM St Mary's Health Center Richmond Heights CenterPointe Hospital St. Charles Barnes-Jewish Hospital St. Louis Christian Hospital - NE/NW St. Louis Forest Park Community Hospital St. Louis St. Alexius Hospital - Broadway Campus St. Louis St. Anthony's Medical Center St. Louis St. John's Mercy Medical Center St. Louis St. Louis University Hospital St. Louis SSM St. Joseph Health Center Wentzville MPC St. Louis Hawthorn St. Louis Total Source: Missouri Department of Mental Health; verified by Hospital representatives to the RPC Task Force In 2010, Adult psychiatric beds account for 57% of all acute psych beds in the Eastern Region; Geriatric beds account for 20% of all psych beds in the Eastern Region, and Child/Adolescent beds account for 23% of all psych beds in the Eastern Region. Due to the operational and clinical challenges of mixing the adult, child, and geriatric psychiatric populations, it is important to note that the Eastern Region may experience capacity constraints in one population on a given day (such as adult or children). Between 2007 and 2010, the Eastern Region had a reduction of 89 acute psychiatric beds (net). A total of 114 beds were reduced by hospitals operating in the City of St. Louis (MPC, Forest Park, Barnes- Jewish Hospital, St. Alexius), while a total of 11 acute psych beds were added by hospitals operating in St. Louis County (SSM St. Mary s and SSM DePaul) and 14 beds were added by hospitals operating in St. Charles County (CenterPointe, SSM St. Joseph). If future reductions in acute psychiatric bed capacity occur in the Eastern Region, it will be important for the State and policy makers to understand the impact on service to specific populations and geographies as these reductions occur. 9

10 d. Capacity for Psychiatric visits to community Emergency Departments (EDs) Community hospital executives have reported to the RPC Task Force that psychiatric visits to community EDs have increased in recent months. The community hospitals in the Eastern Region report that the community ED setting is a clinically inappropriate environment to safely treat persons in psychiatric crisis due to facility constraints, environmental triggers present in hectic ED settings, and issues of staff training. However, the State and community hospitals do not publically report data that provide the scope or scale of the increase in these volumes, and this data was unavailable to the RPC Task Force at the time of publication of this report. While data specific to the St. Louis region was unavailable, DMH provided data on ED visits across the State of MO between 1997 and 2006 that showed that the rate of ED visits in the State s population grew 21% (295.2 visits per 1000 population in 1997 vs visits per 1000 population in 2006). According to DMH data, over this same time period, the rate of mental health visits to the ED grew 50% (7.0 visits per 1000 population in 1997 vs visits per 1000 population in 2006). The same data set shows that the proportion of mental health visits to overall ED visits grew from 1.9% in 1997 to 3% in Eastern Region community hospitals have reported that EDs in the 24 community hospitals that serve the St. Louis region stabilized over 20,000 psychiatric crises in 2009, and saw an additional 8,800 emergency cases involving alcohol and substance abuse, which equates to approximately 80 ED visits each day for psychiatric and substance abuse crises. More recent data, or trended data from previous years, was not available to the RPC Task Force members. The ED closure at Metropolitan Psychiatric Center (MPC) on July 15, 2010 likely will add approximately 12% more psychiatric emergency visits to community EDs, or 3400 additional visits projected during the year, due to the ED closure at MPC, for an additional 9.4 psychiatric or substance abuse emergencies daily. Given these issues, the RPC Task Force members believe that regional reporting of psychiatric ED utilization will be important in the future. In addition to psychiatric and substance abuse ED volumes, one key metric to assess regional inpatient psychiatric capacity at any given time is the number of hours on diversion regional EDs experience for psychiatric patients. However, hospitals currently do not track or publically report this data in the State of Missouri (see Recommendations for subsequent recommendation). 10

11 e. Psychiatric Provider Capacity In 2009, an average of 75 acute psychiatric beds would have been open on an average day, not factoring acute psych beds operated by the VA (see section I, B., b. of this report). One important modifier to this data is the inability of hospitals to mix psychiatric patient types (adult, geriatric, and child), which may limit the given bed capacity on any given day (see section I, B, c. of this report). Another important factor on available psych beds in service on any given day is the human resource capacity to serve these patients in a community hospital setting. While the Eastern Region may have available, though increasingly limited, physical plant capacity to meet current demand, the RPC Task Force members believe that the number of available psychiatrists to serve the population may be a limiting factor currently. Some community hospitals report that they have an insufficient number of psychiatrists on staff to cover the number of beds that they may have open on any given day. Given workforce projections of an increasing shortage of psychiatrists over the next decade, the RPC Task Force members recommend that this situation be monitored and publically reported by the State and Eastern Region community hospitals in the future. C. Community Mental Health Services Capacity Members of the RPC Task Force and MPC Planning Group acknowledge the interrelated nature between regional capacity for community behavioral health services and the need for ED and acute care beds. In 2006, the RHC released a comprehensive report on the capacity within the community behavioral health system, which is available at The RPC Task Force analyzed this report, and concluded that the capacity challenges faced by the Eastern Region community behavioral health system in 2006 are still relevant in In 2006, RHC reported the key statistics regarding capacity: Need for Services An estimated 25,900 36,200 safety net individuals in the Eastern Region are in serious need of psychiatric care. 1 The majority of mental health services for the adult safety net population are coordinated through Department of Mental Health providers, who serve 13,041 unduplicated clients in a given year, or between percent 2 of the safety net population estimated to be in serious need of services. For alcohol and drug abuse services, as noted earlier, an estimated 48,628 safety net individuals in the Eastern Region abuse or are dependent on substances. 3 The state reports that state funded alcohol and 1 Safety net is calculated by adding the number of individuals in the Eastern Region on Medicaid in 2005 (according to the Department of Health and Human Services website) and the number of uninsured individuals in the Eastern Region (according to Kaiser Family Foundation, ). The population for the Eastern Region totals 2,068,000, which is 36 percent of the state population. 2 Equals 12,859 23,159 individuals. Average number of individuals is 18, Safety net is calculated by adding the number of individuals in the Eastern Region on Medicaid in 2005 (according to the Department of Health and Human Services website) and the number of uninsured individuals in the Eastern 11

12 drug abuse providers serve 13,559 unduplicated clients in a given year, or 28 percent 4 of the safety net population estimated to be in need of services. This is a conservative estimate which does not include an estimate for individuals who: 1) have private insurance but lack behavioral health care insurance, or 2) fully exhaust all of their behavioral health care benefits, or 3) have severe diagnosis or service needs and cannot find behavioral health care, or 4) are forensic clients. Analysis completed by RHC in 2006 conservatively estimated that an additional $87 million would be needed annually to provide adequate community behavioral health services to the adult safety net population in the Eastern region. Waiting Lists Seventy-three percent of survey participants utilize a wait list for services, including two Community Mental Health Centers, four affiliates and five alcohol and drug abuse providers. During 2005, a total average of 458 individuals were on the wait lists on any given day, with most of those individuals on the wait lists for alcohol and drug abuse services. An executive summary of the 2006 Eastern Region Behavioral Health Assessment can be found as Appendix B to this report. In addition to the 2006 report, the RPC Task Force members analyzed data provided by the Department of Mental Health regarding length of stay of consumers in programs at various community mental health providers on December 31, As indicated by the chart below, the majority of consumers within these providers had been served either for less than one year, or for over five years. The RPC recommends that the State of MO, Behavioral Health Network (BHN) and St. Louis community further analyze this data to understand if alternative service delivery to the up to one year and greater than five year populations may increase system capacity long-term. Exhibit #6: Length of Stay by Community Mental Health Provider on Dec. 31, 2009 Region (according to Kaiser Family Foundation, ). The population for the Eastern Region totals 2,068,000, which is 36 percent of the state population. 4 Equals 35,069 individuals. 12

13 1 Month 1-2 Months 2-3 Months 3-6 Months 6-12 Months Up to 1 Year 1-2 Years 2-3 Years 3-4 Years 4-5 Years 5+ Years 082 Community Treatment 4% 5% 6% 10% 16% 41% 14% 7% 10% 6% 21% 075 Crider Center 3% 3% 4% 8% 14% 32% 19% 11% 8% 6% 24% 179 Hopewell Center 8% 4% 5% 10% 10% 37% 15% 10% 4% 4% 30% 251 Adapt 2% 2% 2% 6% 6% 18% 15% 14% 11% 5% 36% 257 BJC Behavioral Health 4% 2% 2% 6% 10% 24% 13% 8% 6% 6% 43% 240 Independence Center 1% 1% 0% 5% 8% 16% 12% 11% 6% 7% 48% 241 Places For People 0% 0% 0% 4% 8% 13% 11% 6% 5% 5% 60% Total 6% 4% 4% 9% 13% 36% 14% 11% 7% 6% 27% Source: MO Department of Mental Health One recent study by DMH suggests comprehensive community behavioral health services for a year time period do reduce inpatient and ED psychiatric utilization. As noted in Exhibit 7, the 1,475 clients that had comprehensive community behavioral health services (CPR) had a reduction of 4.4 inpatient days (from days to days), a 61% reduction. This data suggests that additional investment in intensive community behavioral health services can reduce the number of inpatient psychiatric days and psych ED visits in the Eastern Region in the future. Exhibit #7: Outcomes Data for New Adult CPR Admissions* 1/1/2008 through 6/30/2009 Adult CPR 1/1/08-6/30/09 90 Days 180 Days 270 Days 360 Days Pre Post Pre Post Pre Post Pre Post Number of Clients CPS Inpt Days / Client CPS Inpt Adm / Client CPS ER Visits / Client MHN ER (psych) Visits / Client MHN Hosp (psych) Days / Client MHN + CPS Inpt Days / Client MHN + CPS ER (psych) / Client Source: MO Department of Mental Health 13

14 IV. RECOMMENDATIONS 1. Building on the Eastern Region s Community Access Team proposal, a private/public partnership should be established between the State of MO and community hospitals to create psychiatric stabilization model (see Appendix C for detail) to serve those in immediate, urgent need of psychiatric services. Given the importance of these services to patients and families in the region, the RPC Task Force recommends that a broad community consortium that includes the State of MO and community hospitals annually invest the resources needed for the unit to break even. When this stabilization model is implemented, utilize services located at MPC and managed by Bridgeway Behavioral Health currently available for modified medical detoxification referrals. 2. EMS providers and law enforcement personnel should be immediately contacted to ensure proper protocols and Memorandums of understanding are established for referral to this unit. 3. The State should work with the Missouri Hospital Association (MHA) to create an Eastern Region Hospital Collaboration Agreement for psychiatric services. Included in this agreement will be protocols for the transfer of patients evaluated in the psychiatric acute access center/ brief treatment unit and determined to need inpatient medical care, as well as a protocol for equitable participation by hospitals in court-ordered involuntary hospital admissions. Public and routine reporting from the psychiatric acute access center/ brief treatment unit will also be essential. 4. The State, MHA, and the Behavioral Health Network (BHN) should collaborate to assess the utilization of Eastern Region psychiatric beds by providers and courts outside of the St. Louis region. If applicable, the State and MHA should develop statewide protocols for the equitable referral of psychiatric patients to St. Louis providers given current capacity constraints in the Eastern Region. 5. The BHC State of MO, and Eastern Region providers and community members should continue implementation of the region s 2006 and 2009 blueprint for transforming behavioral health services, with priority to those recommendations that will directly assist the region in light of the recent closure of services at MPC (see Appendix D for list of recommendations). 6. The State of MO and BHN should report regional access metrics for behavioral health services on an ongoing basis. As part of this regional reporting, MHA & community hospitals should track and publically report psychiatric ED volumes on a periodic basis. 7. The BHN board of directors should revisit the current BHN by-laws to address the underrepresentation of the hospital community on the board of this organization (see Appendix E for a summary of current BHN by-laws). 14

15 Appendix A Regional Psychiatric Capacity (RPC) Task Force Membership Jim Sanger, Chairperson Chief Executive Officer SSM Health Care St. Louis Sharon Burnett Vice President of Licensure, Regulation & Accreditation Missouri Hospital Association Dwayne Butler Chief Executive Officer BJK People s Health Centers & Hopewell Center Pat Coleman Vice President Operations Behavioral Health Response Tim Dalaviras Executive Director, Hyland Behavioral Health St. Anthony s Medical Center Dolores Gunn, MD Director St. Louis County Department of Health/Corrections Medicine Bethany Johnson-Javois Chief Executive Officer St. Louis Integrated Health Network Mike Morrison Chief Executive Officer Bridgeway Behavioral Health Gary Olson President and Chief Executive Officer St. Luke s Hospital Joseph Parks, MD Chief Clinical Officer Missouri Department of Mental Health Rob Poirier, MD Clinical Chief, Emergency Medicine BJC HealthCare/Washington University School of Medicine Rev. B.T. Rice Pastor New Horizon Seven Day Christian Church Bill Siedhoff Director City of St. Louis, Department of Human Services Mark Utterback President and Chief Executive Officer Mental Health America of Eastern Missouri 15

16 Appendix B Eastern Regional Behavioral Health Initiative 2006 Current State Assessment Executive Summary Introduction In 2006, the Eastern Region Behavioral Health Initiative completed an analysis of the behavioral health system that included: A review and description of the public behavioral health care system at the national, state and local level, An in-depth analysis of the continuum of care available in the Eastern region, A collection of provider service data information for 2005, and An analysis of behavioral health care funding for the Eastern region. The focus of the Eastern Region Behavioral Health Initiative s 2006 Current State Assessment was outpatient services provided by community mental health centers and alcohol and drug abuse agencies. This executive summary is a high level summary of the 2006 assessment. The executive summary highlights the information from the assessment that relates to the closure of Metropolitan St. Louis Psychiatric Center, as data has shown that the lack of community services directly impacts length of stay in inpatient beds. Please review the full 2006 Current State Assessment for more details. Key Findings As a result of the activities and analysis conducted in 2006, the following key findings emerged. 1. The behavioral health system in the Eastern Missouri region is fragmented and has gaps on many levels: a. Limited coordination of health care Stakeholders emphasized that the behavioral and physical health needs of an individual should not be separated they are inextricably linked to the individual s overall health and well-being. However, there is limited coordination between the behavioral health care system and the physical health care system. The behavioral health system is separated from the physical health system in many ways. b. Limited coordination within the behavioral health system Within the behavioral health system, there is limited coordination between providers. For example, clients receive redundant assessments from each different provider/organization. Mental health and substance abuse providers have limited communication with each other and limited knowledge of each others programs. And, although more than half of the adults with severe mental illness in the public mental health system are further impaired by co-occurring substance use disorders, 1 there is limited coordination of mental health and alcohol and drug abuse treatment. 1 Substance Abuse and Mental Health Services Administration, National Mental Health Information Center, Evidence-Based Practices, Co-Occurring Disorders: Integrated Dual Disorders Treatment, Implementation Resource Kit. 16

17 Appendix B c. Limited coordination of community based behavioral health services with inpatient psychiatric services Stakeholders report that individuals often enter into inpatient psychiatric services without appropriate screening for community alternatives and come out of inpatient services without a seamless handoff to ongoing community treatment. 2. It is difficult for some people in need of behavioral health services to find adequate information regarding who can access services and what services are available. A large number and wide variety of formal and informal entry points are available for individuals to make an initial point of contact into the behavioral health system; however, stakeholders believe the general public does not understand the types or breadth of services provided, or the areas served by specific providers. 3. Clients and family members identify a combination of practical barriers and limited social supports that prevent them from accessing quality behavioral health services. Examples of practical barriers include limited transportation and limited ability to receive appropriate medications. Examples of limited social supports include the limited stable housing and employment, the stigma of mental illness and substance abuse, and the lack of respect from professionals, family and friends. 4. Accounting for dollars spent for behavioral health services in the region is challenging. Conservative estimates have that an additional $87 million would be needed to provide adequate behavioral health services to the adult safety net population in the Eastern region. Several measures highlight the limited funding for safety net behavioral health services in the Eastern region: a. Waiting Lists Because of limited funding and restrictions on how funding can be used, individuals with behavioral health needs in the safety net system are often unable to access care unless they are in a crisis situation. Existing capacity for community based mental health and alcohol and drug abuse services is not meeting service demand; many behavioral health organizations have a wait list for services. The current mental health system responds primarily to individuals in crisis, and has less emphasis on prevention and early intervention efforts. b. Serving a lower percentage of the population than other regions The money invested in the Eastern region public behavioral health system served a much lower percentage of the population than the percentage of people served in other regions of the state. For example, the state Comprehensive Psychiatric Services 2005 expenditures in the region served 7.5 citizens per 1,000 population (reported by the CPS Division) which is less than half the penetration rate of 15.9 per 1,000 observed in the Northwest Region (Kansas City region) and a statewide average of 12.4 people per 1,000. This finding may suggest the need for increasing community-based treatment options in the region. c. Decreasing state and federal funds Changes in the federal and state level have resulted in proportionately less funds available for behavioral health services; this has caused a noticeable erosion in services in safety net behavioral health services across the country. Flow through the Current Behavioral Health System The following diagram provides an overview of the organizations providing behavioral health services and the way individuals currently navigate the system. 17

18 Behavioral Health System ORGANIZATION FLOW* * This map reflects the way consumers currently navigate the mental health system, not a recommended flow for the future. Initial Assessment and/or Screening conducted by any of the agencies/individuals on earlier chart (or any organization in dotted box below); may not address the dichotomy of issues for individuals with cooccurring disorders Appendix B Emergent Need need for immediate, inpatient care; medical detox for substance abuse; immediate danger to self or others for mental health Urgent Need immediate, not inpatient Crisis beds assigned through BHR; located at Hopewell, COMTREA, Crider Routine need Where a person receives treatment depends on their initial point of contact, available capacity, where they live, severity of diagnosis, source of funding, and staff training and knowledge. No Treatment Issue was resolved or diffused, or there was no follow-up, or no treatment was needed at this time (but may be in the future). Corrections Medicine Inpatient BJC, CenterPointe, Christian, DePaul, Des Peres, Forest Park, Jefferson Memorial, MPC, St. Alexius, St. Anthony s Hyland, St. John s Mercy, St. Joseph, SLU, St. Louis Psychiatric Rehabilitation Center**, St. Mary s ** provides long-term treatment focused on forensic or treatment resistant patients. Limited discharges. Medical ER BJC, Christian, DePaul, Des Peres, Forest Park, Jefferson Memorial, St. Alexius, St. Anthony s Hyland, St. John s Mercy, St. Joseph, SLU, St. Mary s Outpatient: CMHC, Affiliate, Alcohol and Drug Abuse Providers, Community Agencies, Private Hospitals Residential: substance abuse or psychiatric group homes (run by CMHCs or independent) No further treatment Social Detoxification Bridgeway Behavioral Health, Preferred Family Healthcare, Queen of Peace Center Next day appointment assigned through BHR Modified Medical Detox- Bridgeway Behavioral Health Community Mental Health Center BJC, COMTREA, Crider, Hopewell Community Substance Abuse Providers Assisted Recovery Centers, Community Alternatives, GFI Services, Harris House, Hopewell Center, Hyland Behavioral Health, Provident, St. Louis Metro Treatment Law Enforcement, CIT, Mental Health and Drug Courts, Corrections/Probation Where a person receives treatment depends on their initial point of contact, available capacity, where they live, severity of diagnosis, source of funding, and staff training and knowledge. Affiliate Provider ADAPT, Independence Center, Places for People DMH Funded Substance Abuse Provider BASIC, Bridgeway Counseling, Center for Life Solutions, COMTREA, New Beginnings, Preferred Family Healthcare, Queen of Peace Center, Salvation Army Harbor Light, St. Patrick Center, WestEnd Clinic Community Social Service and Counseling Agencies*** Catholic Charities and Family Services, Grace Hill, George Washington Carver House, Good Samaritan, Guardian Angel, International Institute, Jewish Family and Children, Kingdom House, Neighborhood Houses, Northside Community Center, PAKT Community Resource, Provident, Salvation Army, Urban League, Youth and Family Center, Wesley House Assoc. ***This list includes United Way agencies, but is not exhaustive of all community 18 agencies.

19 Appendix B Key Data from 2005 Clients Served and New Admissions Together, the community mental health centers, alcohol and drug abuse providers and affiliate organizations in the Eastern region admitted 15,869 adults in Alcohol and drug abuse providers admitted half of those individuals (7,951), community mental health centers admitted 44 percent (6,973), and the affiliate providers admitted six percent (945). Adult Clients Admitted -- 15,869 total Affiliate 6% ADA 50% CHMC 44% Served vs. Admitted TYPE OF PROVIDER TOTAL SERVED NEW ADMISSIONS Community Mental Health Centers 12,175 6,973 Affiliate Organizations 1, Alcohol and Drug Abuse Providers 13,559 7,951 TOTALS 26,944 15,869 Referral Sources For all types of providers, most individuals refer themselves to these providers for service. Other significant referral sources changed for community mental health centers, affiliate organizations and alcohol and drug abuse providers. Referral Sources COMMUNITY MENTAL HEALTH CENTERS AFFILIATE PROVIDERS REFERRAL SOURCE BHR/Crisis Service 5% -- 1% Courts 6% 3% 19% DMH/MPC 8% 4% 1% Family 9% 9% 7% Hospital/Inpatient/Medical 13% 31% 3% Doctor Law Enforcement 5% <1% 17% Other CMHCs 3% 21% 1% Other Substance Abuse 1% -- 15% Program Self 52% 31% 35% ALCOHOL AND DRUG ABUSE PROVIDERS 19

20 Appendix B Services Provided For community mental health centers, affiliate providers and alcohol and drug abuse providers, most individuals received outpatient services (47 percent for CMHCs/affiliates, 53 percent for alcohol and drug abuse providers). Services Provided Community Mental Health Centers and Affiliate Providers SERVICE PERCENTAGE Outpatient Office 47% Community Support/Home Based 16% Case Management 15% Therapy/Counseling 9% Medication Clinics 9% Day Programs 3% Residential <1% Crisis Beds <1% Services Provided Alcohol and Drug Abuse Providers 2 SERVICE PERCENTAGE Outpatient 42% CSTAR 18% Residential Support 15% Therapy/Counseling 15% Community Support 7% Detox 4% Available State Funded Community Based Beds Available Beds and Average Daily Census CMHCS AND AFFILIATES ALCOHOL AND DRUG ABUSE Type of Bed # of Beds Avg Daily Census # of Beds Avg Daily Census Residential Care Crisis Dedicated Detox NA NA Need for Services An estimated 25,900 36,200 safety net individuals in the Eastern Region are in serious need of psychiatric care. 3 The majority of mental health services for the adult safety net population are coordinated through Department of Mental Health providers, who serve 13,041 unduplicated clients in a given year, or between percent 4 of the safety net population estimated to be in serious need of services. 2 Not included in this total are services provided by only one agency. Case management services (462 services) and day program services (1,696 services) were provided by only one alcohol and drug abuse provider. 3 Safety net is calculated by adding the number of individuals in the Eastern Region on Medicaid in 2005 (according to the Department of Health and Human Services website) and the number of uninsured individuals in the Eastern Region (according to Kaiser Family Foundation, ). The population for the Eastern Region totals 2,068,000, which is 36 percent of the state population. 4 Equals 12,859 23,159 individuals. Average number of individuals is 18,

21 Appendix B For alcohol and drug abuse services, as noted earlier, an estimated 48,628 safety net individuals in the Eastern Region abuse or are dependent on substances. 5 The state reports that state funded alcohol and drug abuse providers serve 13,559 unduplicated clients in a given year, or 28 percent 6 of the safety net population estimated to be in need of services. This is a conservative estimate which does not include an estimate for individuals who: 1) have private insurance but lack behavioral health care insurance, or 2) fully exhaust all of their behavioral health care benefits, or 3) have severe diagnosis or service needs and cannot find behavioral health care, or 4) are forensic clients. Waiting Lists Seventy-three percent of survey participants utilize a wait list for services, including two Community Mental Health Centers, four affiliates and five alcohol and drug abuse providers. During 2005, a total average of 458 individuals were on the wait lists on any given day, with most of those individuals on the wait lists for alcohol and drug abuse services. Community mental health centers and affiliates averaged 106 individuals on their wait lists (average of 18 individuals per organization). This is a conservative estimate of the number of individuals waiting for care because of several factors: some individuals give up waiting until a crisis occurs, some organizations do not keep formal wait lists, some organizations cap their wait lists, and some organizations have a wait list but do not keep track of the number of individuals on it. Alcohol and drug abuse providers averaged 352 individuals on their wait lists (average of 70 individuals per organization). Although individuals may be on the wait lists at multiple organizations, this is a conservative estimate of the number of individuals waiting for care because of the reasons noted above. Nine organizations (60 percent of survey participants) kept data about the length of time individuals were on their wait list. Average Length of Time on Wait List LENGTH OF TIME NUMBER OF ORGANIZATIONS 31+ days days days days 1 5 Safety net is calculated by adding the number of individuals in the Eastern Region on Medicaid in 2005 (according to the Department of Health and Human Services website) and the number of uninsured individuals in the Eastern Region (according to Kaiser Family Foundation, ). The population for the Eastern Region totals 2,068,000, which is 36 percent of the state population. 6 Equals 35,069 individuals. 21

22 Appendix C Stabilization Center Model Detail This section includes the following documents: 1. Psychiatric Acute Access Center and Brief Treatment Unit (PAACBTU) Model 2. Psychiatric Acute Access Center and Brief Treatment Unit Model Description 3. Map of the St. Louis Estimated Daily ED Use: Psychiatric and Substance Abuse Primary Diagnosis 4. Demand and Volume Assumptions for PAACBTU 5. PAACBTU Financial Summary 6. PAACBTU Revenue Model 7. Stabilization Center Model Data Sources and Assumptions 22

23 Stabilization Center Model revised from CATT: Eastern Region Crisis Stabilization 3/ 25/ 09 The Stabilization Center provides 24/7 behavioral health assessment, triage and referral to appropriate care in least restrictive environments, with available observation or crisis stabilization beds. Appendix C, Section 1 If medically stable and permitted by EMTALA Referred by community resources * ADA provider * CMHC * Advocacy Organization * Other If medical care needed G Hospital Emergency Dept. EMS triage to hospital ED or Stabilization Center H F E Escorted by CIT officer or other law enforcent Court referred Referred by BHR Call Center Escorted by BHR Mobile Outreach Team (MOT) Self Referral Urgent Community Care Access Social Detox Urgent (All transports in secure passenger vehicle if medically stable) Satellite Access Center(s) county A B MPC Stabilization Center (Assessment/ Triage) Routine D Satellite Access Center(s) county Emergent Ambulance transport Bed Placement: Structure for equitable bed assignment (communication with hospital intake depts.) Brief Treatment Unit C BHR-MOT from contracted hospital ED Med/Surg. Hospital if medically Secured Medical Detox (Bridgeway/MPC) Inpatient psychiatric hospital unit I J Community Stabilization Beds Referred to community resources * ADA provider * CMHC *Advocacy Organizations *Other If medical care needed

24 Appendix C, Section 2 Psychiatric Acute Access Center and Brief Treatment Unit Model Detail Background Emergency Departments (EDs) in the 24 community hospitals that serve the St. Louis region stabilize over 20,000 psychiatric crises each year, and see an additional 8,800 emergency cases involving alcohol and substance abuse. This combines to about 80 ED visits each day. The ED closure at Metropolitan Psychiatric Center (MPC) on July 15, 2010, stretched the region s ED capacity even farther by adding almost 12% more psychiatric emergency visits: 3400 projected during the year for an additional 9.4 psychiatric or substance abuse emergencies daily. Closing fifty inpatient psychiatric beds at MPC makes it even more challenging to place patients who need psychiatric care. The result is extremely long waits in the region s EDs for psychiatric patients, in a medical environment that was not designed to safely provide emergency psychiatric care. Psychiatric patients on average spend six to eight hours in busy community hospital emergency departments, and sometimes as long as 20 hours waiting for inpatient psych bed availability. By comparison, the average wait time for patients in the MPC Emergency Department was 2.6 hours. In March 2009 the Community Access Transformation Team (CATT) developed a regional plan for psychiatric crisis stabilization that described an assessment/triage center at MPC that would help direct consumers to appropriate care in the last restrictive environment and link services cross the range of community providers. The intent was not to divert consumers from community hospital EDs, however, and EMS responders were not specifically included in the service flow. Crisis stabilization beds (for 23-hour observation) did play a significant role in the original CATT model. The Stabilization Center Model The model currently being developed for review has two key components: Psychiatric Acute Access Centers and a Brief Treatment Unit (see attached flowchart). This model intentionally builds upon a similar proposal submitted to DMS by the Eastern Region Community Access Transformation Team (CATT). 1) The Psychiatric Acute Access Center involves a psychiatric assessment and triage facility that blends urgent care and emergency care models. One location (A: located at MPC s current Emergency Department site) would provide 24/7 assessment, triage and placement services under the direction of a Psychiatrist Medical Director. Additional satellite locations (B) could be developed in suburban locations and would likely be staffed for 12 hours daily, during peak use times. Consumers come directly to the Access Centers (A or B) or are directed by community, legal or law enforcement agencies through various routes (D F). In many cases consumers may also be referred out to these agencies for support services (D and E) if more intensive observation or inpatient treatment is not necessary. If it appears that medical care may be necessary the consumer should be transported by ambulance to the nearest hospital Emergency Department (G). 24

25 Appendix C, Section 2 Data suggest that approximately 35% of ED users with psychiatric crises come by themselves or accompanied by family or friends, fewer than 5% are escorted by police, and about 10% are directed by community agencies. The majority of persons in psychiatric crisis arrive in the ED via ambulance roughly 60% (H). This is a critical factor if the Stabilization Center model is to accomplish a key goal: to appropriately divert people who do not require a hospital s medical care to a treatment center better suited to safely assess, stabilize and obtain proper treatment for a psychiatric crisis. EMS personnel are well suited to triage the medical conditions present in a psychiatric crisis that require hospital ED care and to transport others to a specialty psychiatric and substance abuse treatment center. Existing patterns of hospital ED use by those with psychiatric or substance use crises are being examined to determine the best initial placement for a satellite Access Center in the suburban St. Louis area. Preliminary analysis indicates that over 25% of the current psychiatric and substance abuse volume in hospital EDs could be appropriately diverted to Access Centers, reducing the region s daily ED load by over 22 visits, to about 60 visits daily. Most of this would be accomplished by re-directing EMS to a facility better suited for psychiatric stabilization, but the locations must be reasonably convenient, provide ready EMS access and rapidly accommodate these healthcare professionals. Proper medical directives and training must be in place for an appropriate medical triage system so that EMS personnel appropriately transfer non-medical cases from an ED setting to the stabilization service. 2) The Brief Treatment Unit (C) would operate from a 16 or 25-bed platform previously used for inpatient psychiatric treatment at MPC. This unit would offer what are typically called 23- hour observation beds, although current models allow brief stays up to 72 hours. The Brief Treatment Unit would provide a safe physical environment, sufficient psychiatric, medical and nursing care and a therapeutic setting to effectively stabilize a patient who does not require a more lengthy and intensive inpatient psychiatric admission. Utilization data from the region s hospitals indicates that about five patients each day from the subset that would be diverted to an Access Center have inpatient psychiatric hospitalization of two days or less. This conservative estimate accounts for an average daily census of almost ten Brief Treatment Unit patients. There is the potential for almost seven additional Brief Treatment admissions each day if a much larger group of patients who discharge from inpatient psych units within two days were included those that are predicted to continue presenting to hospital EDs rather than diverting to Access Centers. If clear Brief Treatment Unit admission criteria were followed it should not violate EMTALA regulations to make a clinical decision for admission to an Brief Treatment Unit. If the Brief Treatment Unit can be appropriately managed to ensure brief stays it can not only assist with ED throughput, but can also contribute significantly to inpatient psychiatric unit capacity. Managing Inpatient Psychiatric Bed Capacity. There is one additional function of the Stabilization Center model to discuss: equitable placement of the patients who present to Access Centers and require admission to Inpatient Psychiatric Units (I). The current model estimates this to be about five patients daily. There must be an agreed upon system or algorithm to ensure responsive bed placement. This is 25

26 Appendix C, Section 2 essential to prevent the Observation Unit from becoming an overflow unit for placing patients who need treatment on an inpatient psych unit. The flowchart indicates the Bed Placement function (J) to direct patients from hospital EDs to the Brief Treatment Unit as well as from Access Centers to hospital inpatient psych units. There has been some support for expanding this function to include equitable distribution of the increasing volume of court-ordered treatment. There has also been discussion of developing a regional psychiatric bed placement system with factors such as psychiatric patients residential zip code and hospital bed capacity to determine incentives and penalties for admitting or transferring patients. Regardless of the eventual scope, it is clear that the Stabilization Center model will require a more formal placement agreement among the region s hospitals than is currently in place. Operating the Stabilization Center Facilities. A concluding note is needed to raise the complex of issues involved in the operation of a regional model for psychiatric and substance abuse crisis stabilization. While the need for better coordination of mental health services seems clear and there appears to be strong motivation from community providers in outpatient organizations as well as from hospitals, there are significant issues to resolve in developing a successful operating structure. Considerations include designation of a provider number that doesn t jeopardize existing healthcare operations, identifying an operating entity without incurring unnecessary administrative overhead expense, and developing relationships of trust across organizations with little history of cooperation or shared incentives. The role of Missouri s Dept. of Mental Health in providing ongoing support must be clarified as well, and the possibility of public/ private partnership with the regions community hospitals must be explored. 26

27 STL Region Estimated Daily ED Use: Psychiatric and Substance Abuse Primary Diagnoses Appendix C, Section 3 27

28 Potential Access Center Users (daily) = Combines all Psych & ASA (w/o medical needs) from Hospital EDs and prior MPC users Appendix C, Section 4 Data Source 1 Who can be diverted from ED to Access Center? Data Source 2 Est. % for each Mode Mode of Arrival at Likelihood of Access Center Directing Transports Ambulance (EMS) 60% 40% Police 5% 25% 1.03 Self/Family 35% 5% % Predicted Access Center Users Access Center Hospital EDs Predicted Users (daily) = Percentage = 27.0% 73.0% Who can benefit from a Brief Treatment Psychiatric Unit? Predicted Access Center Discharges Access Center Total Admit Inpatient Discharge to Home Predicted Hospital ED Discharges Admit Inpatient Discharge to Home Hospital ED Total Psych % 48.17% 51.84% 48.17% Data Source ASA % 76.82% 23.17% 76.82% Combined Psych & ASA % Psych admissions w/ LOS 2 days = 18.23% # Brief Psych admissions % ASA admissions w/ LOS 2 days = 45.03% # Brief ASA admissions Predicted Admissions from Access Center = % Predicted Average Length of Stay = 1.5 Predicted Admissions from EDs = 4.70 Predicted Average Daily Census = PredictedTotal Daily Admissions = 6.87 Percent of these patients meeting criteria for Brief Treatment Unit transfer? 28

29 Scenario A MPC location only Appendix C, Section 5 a) Acute Psychiatric Access Center b) 16-bed Brief Treatment Unit Acute Psychiatric Access Center Initial Capital = 16-bed Brief Treatment Unit Initial Capital = Existing Hospital Provider # New Hospital Provider # Excluded IMD facility Annual Revenue $995,322 $995,322 $995,322 Annual Staffing Expense $1,992,226 $1,992,226 $1,992,226 Other Operating Expenses $680,553 $680,553 $680,553 $575,000 ($1,677,457) ($1,677,457) ($1,677,457) Annual Revenue $3,072,801 $2,524,436 $1,741,057 Annual Staffing Expense $1,351,603 $1,351,603 $1,351,603 Other Operating Expenses $428,630 $428,630 $428,630 $435,000 $1,292,568 $744,203 ($39,176) Annual Revenue $4,068,123 $3,519,758 $2,736,379 Annual Staffing Expense $3,343,829 $3,343,829 $3,343,829 Other Operating Expenses $1,109,183 $1,109,183 $1,109,183 $1,010,000 ($384,889) ($933,254) ($1,716,633) Combined Units Initial Capital = Scenario B MPC location with: Satellite location with: a) Acute Psychiatric Access Center b) 16-bed Brief Treatment Unit c) Acute Psychiatric Access Center Acute Psychiatric Access Centers Initial Capital = Initial Capital = Existing Hospital Provider # New Hospital Provider # Excluded IMD facility Annual Revenue $1,194,386 $1,194,386 $1,146,353 Annual Staffing Expense $2,866,815 $2,866,815 $2,866,815 Other Operating Expenses $1,036,110 $1,036,110 $1,036,110 $1,750,000 ($2,708,539) ($2,708,539) ($2,756,572) 16-bed Brief Treatment Unit Initial Capital = Annual Revenue $3,072,801 $2,524,436 $1,741,057 Annual Staffing Expense $1,351,603 $1,351,603 $1,351,603 Other Operating Expenses $428,630 $428,630 $428,630 $435,000 $1,292,568 $744,203 ($39,176) Annual Revenue $4,267,187 $3,718,822 $2,887,411 Annual Staffing Expense $4,218,418 $4,218,418 $4,218,418 Other Operating Expenses $1,464,740 $1,464,740 $1,464,740 $2,185,000 ($1,415,971) ($1,964,336) ($2,795,748) Combined Units 29

30 Appendix C, Section 6 Scenario A MPC location only a) Acute Psychiatric Access Center b) 16-bed Brief Treatment Unit Existing Hospital Provider # New Hospital Provider # Excluded IMD facility a) Acute Psychiatric Access Center ** Daily Daily Annual ** Daily Daily Annual ** Daily Daily Annual Total Predicted Daily Users = Billable visits Revenue Revenue Billable visits Revenue Revenue Billable visits Revenue Revenue % directable to single MPC site = 75% Medicare 1.94 $68 $24,901 Medicare 1.94 $68 $24,901 Medicare 1.94 $68 $24,901 Actual Predicted Daily Volume = Medicaid 2.79 $1,405 $512,748 Medicaid 2.79 $1,405 $512,748 Medicaid 2.79 $1,405 $512,748 Commercial 2.10 $1,118 $408,185 Commercial 2.10 $1,118 $408,185 Commercial 2.10 $1,118 $408,185 Psych ASA Self 2.38 $24 $8,694 Self 2.38 $24 $8,694 Self 2.38 $24 $8,694 Actual Visits Other 0.21 $112 $40,794 Other 0.21 $112 $40,794 Other 0.21 $112 $40,794 Admission Rate 51.8% 23.2% $2,727 $995, $2,727 $995, $2,727 $995,322 ** Billable Visits ** Access Center revenue adjusted for inpatient admissions - no ED billing if pt. admitted b) 16-bed Brief Tratment Unit Daily Bed capacity = 16 users Predicted Occupancy Rate = 88% Medicare 3.06 $1,988 $725,739 Medicare 3.06 $1,988 $725,739 Medicare 3.06 $1,988 $725,739 Predicted Average Daily Census = Medicaid 4.29 $3,649 $1,331,744 Medicaid 4.29 $2,146 $783,379 Medicaid 4.29 $0 $0 Commercial 3.14 $2,512 $916,947 Commercial 3.14 $2,512 $916,947 Commercial 3.14 $2,512 $916,947 Predicted ADC from Demand Analysis = Self 3.29 $33 $12,018 Self 3.29 $33 $12,018 Self 3.29 $33 $12,018 Predicted Psych Census = Predicted ASA Census = Daily Revenue Annual Revenue Other 0.30 $237 $86,354 Other 0.30 $237 $86,354 Other 0.30 $237 $86, $8,419 $3,072,801 $6,916 $2,524,436 $4,770 $1,741, Total = $11,146 $4,068,123 Total = $9,643 $3,519,758 Total = $7,497 $2,736,379 Daily users Daily Revenue Annual Revenue Daily users Daily Revenue Annual Revenue Scenario B MPC location with: Satellite Location with: a) Acute Psychiatric Access Center b) 16-bed Brief Treatment Unit c) Acute Psychiatric Access Center a) Acute Psychiatric Access Center Total Predicted Daily Users = % directable to two Access Center sites = 90% Actual Predicted Daily Volume = MPC Satellite Medicare 2.33 $82 $29,882 Medicare 2.33 $82 $29,882 Medicare 2.33 $82 $29,882 Volume % 65% 35% Medicaid 3.34 $1,686 $615,297 Medicaid 3.34 $1,686 $615,297 Medicaid 3.34 $1,686 $615,297 # Visits Commercial 2.52 $1,342 $489,822 Commercial 2.52 $1,342 $489,822 Commercial 2.52 $1,342 $489,822 Psych ASA Self 2.86 $29 $10,432 Self 2.86 $29 $10,432 Self 2.86 $29 $10,432 Actual Visits Other 0.25 $134 $48,953 Other 0.25 $134 $48,953 Other 0.25 $3 $919 Admission Rate 51.8% 23.2% $3,272 $1,194, $3,272 $1,194, $3,141 $1,146,353 ** Billable Visits ** Access Center revenue adjusted for inpatient admissions - no billing if pt. admitted b) 16-bed Brief Treatment Unit Daily Bed capacity = 16 users Predicted Occupancy Rate = 88% Medicare 3.06 $1,988 $725,739 Medicare 3.06 $1,988 $725,739 Medicare 3.06 $1,988 $725,739 Predicted Average Daily Census = Medicaid 4.29 $3,649 $1,331,744 Medicaid 4.29 $2,146 $783,379 Medicaid 4.29 $0 $0 Commercial 3.14 $2,512 $916,947 Commercial 3.14 $2,512 $916,947 Commercial 3.14 $2,512 $916,947 Predicted ADC from Demand Analysis = Self 3.29 $33 $12,018 Self 3.29 $33 $12,018 Self 3.29 $33 $12,018 Predicted Psych Census = Predicted ASA Census = Existing Hospital Provider # New Hospital Provider # Excluded IMD facility Daily users **Daily Revenue Daily Revenue Annual Revenue Annual Revenue Other 0.30 $237 $86,354 Other 0.30 $237 $86,354 Other 0.30 $237 $86, $8,419 $3,072,801 $6,916 $2,524,436 $4,770 $1,741, Total = $11,691 $4,267,187 Total = $10,189 $3,718,822 Total = $7,911 $2,887,411 Daily users Daily users **Daily Revenue Daily Revenue Annual Revenue Annual Revenue Daily users Daily users **Daily Revenue Daily Revenue Annual Revenue Annual Revenue

31 Appendix C, Section 7 Psychiatric Acute Access Center and Brief Treatment Unit Assumptions and Data Sources for Proposed Models This document details the source data and assumptions for sections 4, 5 and 6 of Appendix C. 1. Demand-Volume Assumptions The potential number of daily Access Center users (82.54) was derived from HIDI data from Q Q describing adult Psychiatric visits to community hospital EDs in the St. Louis region (omitting organic diagnoses, such as dementia), coupled with visits related to Alcohol and Substance Abuse diagnoses. ED visits that required medical procedures (indicated by E codes) were eliminated from the count. The average daily number of ED visits from MPC (derived from MPC s ED stats from Jan. 1 Apr. 15) was added to the average daily volume from community hospital EDs. The predicted number of psychiatric and substance abuse patients diverted from community hospital EDs to an Acute Psychiatric Access Center (22.29) may be adjusted to account for more subjective variables, through a two-step process. First, the transport mode for patients to arrive at the ED (ambulance, police or self/family) was derived from sample data from the ED at Barnes-Jewish Hospital in combination with the referral source information from patients admitting for inpatient care at MPC. These categories are best fit estimates from these two sources and can be adjusted as the model is tested. The second set of variables is an estimate of the likelihood that each of the three transport modes can be directed to use a Psychiatric Access Center instead of a community hospital ED. It is clear that the success of the model relies most heavily on ambulance service providers, with EMS responsible for the transporting the majority of patients as well as being the most directable source of patients for the acute Psychiatric Access Center. The third volume assumption is the predicted daily number of patients that would use the Brief Treatment Unit (6.87) for a short-term inpatient psychiatric stabilization. This is derived from the HIDI dataset referenced above, but also takes into account the percentage of both psychiatric and alcohol/substance abuse patients that are admitted to inpatient treatment versus discharged to the community. Additionally, the percent of patients that admit for inpatient treatment but remain for two days or less is also determined. This is a conservative predictive model that assumes that the clinical judgment behind hospital admission will not change and that criteria can be developed to help determine the patient characteristics most likely to benefit from brief stabilizing care rather than requiring a full course of inpatient treatment. There is a further adjustment variable for the average length of stay on the brief treatment unit (set at 1.5 days) that yields an average daily census (ADC) of 10.3 patients. 2. Financial Summary The analysis in this worksheet simply combines the results of the cost and revenue models. It should be noted that any adjustment to cost and revenue analyses will be update the final Financial Summary as well. 31

32 Appendix C, Section 7 3. Revenue Assumptions Two scenarios are examined in this analysis: Scenario A, with an Acute Psychiatric Access Center and a 16-bed Brief Treatment Unit at the MPC location, and Scenario B, which add an additional Acute Psychiatric Access Center at a suburban satellite location. Data used in the first step of this analysis extracts payer source information from the HIDI dataset from Q Q1 2010, referenced above, weighted to account for the funding differences between psychiatric and alcohol/substance abuse populations. Volume data for these patient categories is updated based on the demand assumptions set in the worksheet described above. There are several additional volume adjustments on this worksheet: occupancy rate has been set at 88% for the private-room configuration at MPC, and the original volume estimates were reduced by an addition 25% for the MPC-only scenario and by 10% in the two-site satellite scenario. It should be noted that there is no ED visit reimbursement for Acute Psychiatric Access Center visits that result in admission to a hospital or ICU bed, inpatient psychiatric unit bed or Brief Treatment Unit bed. ED visit rates are calculated from the collected payments for the ED at MPC from FY 2008 through FY2010. While a facility licensed as an Institute for Mental Disease (IMD) cannot receive Medicaid payment for the inpatient treatment of patients aged 18 through 64, ED services for this group can be reimbursed. It is also important to note that the IMD Medicaid inpatient exclusion does not apply to hospitals licensed for 16 or fewer beds. Reimbursement rates for the Brief Treatment Unit from each payer type are based on the range of existing hospital payment rates for inpatient psychiatric care in the St. Louis region. Three models are presented, using rates from hospitals with: an existing med/surg Medicare provider number, a new hospital provider number that would not be based on existing med/surg services at the hospital, and an IMD license which eliminates the Medicaid inpatient reimbursement. The model that operates the Brief Treatment Unit as part of an existing hospital with a shared provider number offers the best reimbursement; if the provider number were shared with a teaching hospital the Medicaid reimbursement could be up to one-third higher than estimated in this worksheet. 32

33 Appendix D Regional Psychiatric Capacity Task Force Recommendations Directly Addressing Metropolitan St. Louis Psychiatric Center (MPC) Closure (Taken from RHC 2006 and 2009 Recommendations) 33