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Mental patients turning to ERs

Cuts force many to try hospitals

Boston emergency rooms are grappling with soaring numbers of mental patients this year as cuts in insurance for the poor, coupled with slashed services at community clinics, leave patients with few options but to show up at the nearest hospital.

Massachusetts General Hospital's emergency room saw a 49 percent jump in psychiatric patients from April of last year to April of this year, an increase that has held steady over the summer, and the ER at Boston Medical Center is struggling to accommodate 20 percent more psychiatric patients than it saw last year.

"Instead of being with people who know how to talk to someone who is psychotic, the patient is on a cot in an emergency room, possibly restrained," said Dr. Mary Anne Badaracco, chief of psychiatry at Beth Israel Deaconess Medical Center.

In April, 36,000 people in Massachusetts lost their insurance after cutbacks in MassHealth, the state's insurance program for the poor. According to the Massachusetts Department of Mental Health and community care providers, between 14,000 and 15,000 of those people use psychiatric care.

Those patients are squeezed from both sides: At the same time they lost their insurance, the community health centers where they traditionally received their mental care lost their state funding and are now struggling themselves, often turning away patients or placing them on long waiting lists.

Dimock Community Health Center in Roxbury, for instance, turns away about 30 to 40 patients a day seeking care, and no longer gets reimbursed from DMH to see uninsured psychiatric patients in their outpatient clinic.

"The question is what is happening to these clients," said Dr. Bruce Bird, former chief executive of North Suffolk Mental Health Association, which now turns away dozens of patients every month because of budget cuts.

Gail Lesley, a psychiatric nurse hired by Mass. General to handle uninsured patients flooding its emergency room, says she sees patients wait months for an appointment with a therapist. In the meantime, if a crisis strikes, they often have no choice but to show up at a hospital. "Sometimes clients are discharged from jail with a three-day supply of medication," said Lesley.

Compounding the problem for hospitals, as many as 75 percent of these psychiatric patients also abuse alcohol or drugs and are often intoxicated when they come to the ER, making their underlying mental illness nearly impossible to treat. `People have to go through detox in the emergency room," said Dr. Lawrence Park, director of acute psychiatry service for Mass. General.

"Alcohol withdrawal is a potentially life-threatening condition. If we can't find a place for them, we have to treat it," he said. The number of detox beds in the state dropped dramatically over the past year, from 997 to 420, and the state cut sharply back on money available to fund substance-abuse programs.

Today, because of a drop in state reimbursement, Dimock can afford to fill just seven beds. In the emergency room, intoxicated patients can wait for days for a space to open up in a proper treatment facility. In the meantime, emergency rooms stretch their resources, often assigning nurses to monitor the patient around the clock.

"It takes away services and staff from other people," said Park, whose staff recently treated a psychiatric patient in the ER for five days while trying to find a detox facility, psychiatrists, and rehabilitation for the patient.

The Legislature pledged to partly restore the MassHealth cuts in October, but getting uninsured patients back into the mental health system can be difficult.

"You go for five or six months without coverage and it's not a question of flipping the switch and all 36,000 people will come back on," said Michael Norton, director of behavioral health programs for the state Division of Medical Assistance, which administers Medicaid. "Right now we're already beginning to engage folks around strategies.'

But Dr. Peter Evers, chief of behavioral health at Dimock, is skeptical. "Most of these people are homeless, and it's not just a question of picking up the phone and saying, `Good news. You're back on,' " he said. "The really sad thing is that it takes an awful lot for someone who has this disease to pick up the phone and ask for help."

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