How Well Are We Serving People with Mental Illness?

An interview with Dr. Michael Trangle, associate medical director of behavioral health for Health Partners

Dr. Trangle
Thousands of Minnesotans are affected by mental illness each year, including bipolar disorder, major depression, obsessive compulsive disorder, post-traumatic stress, and schizophrenia. The system of care is complex and involves multiple funding streams and separate agencies/clinics/facilities which can result in gaps in services and a lack of access to services.
The East Metro Mental Health Roundtable is partnering with providers of mental-health referrals, services, and follow-up care to improve access to the most appropriate and cost-effective mental health services in Ramsey, Washington, and Dakota counties.  
As part of this effort, Dr. Michael Trangle leads a subcommittee that is looking at ways to reduce barriers to patient flow between hospitals and community services. Wilder Research is tracking metrics to measure progress.
Q: Where can adults who are experiencing a mental health crisis get help in the east metro area?
A: People in crisis generally go or are taken to hospital emergency rooms because it has been the only option. But last year, an Adult Mental Health Urgent Care Center opened in Saint Paul specifically to better serve people in crisis and their families. It offers walk-in assessments, stabilization services, psychiatric services, and fast-access to referrals to community resources. This option can often provide more appropriate and cost-effective services than a hospital emergency room can.

In addition to crisis services, there are a number of longer-term mental health services available to Twin Cities east metro residents. These services include adult foster care; intensive, residential and time-limited services from Anoka-Metro Regional Treatment Center; or one of the 8 IRTS (Intensive Residential Treatment Services) serving the area. Another option is to receive intensive, long-term outpatient care provided by Assertive Community Treatment Teams. There are also a number of facilities offering chemical dependency services and others that treat medical and psychiatric conditions including nursing homes, assisted living, and Minnesota Extended Treatment Options (METO). There is also a system of public and private clinics/offices with individual psychotherapy, family therapy, marital therapy, and psychiatric services available.
Q: With all of those services and options, why aren’t people getting the help they need?
A: There are a number of barriers for people to get the right treatment. One of the most frequently cited is lack of knowledge by consumers on how to navigate the system. Another is the complex payment systems which affect both eligibility and the assessment process depending on a person’s type of insurance coverage or lack of coverage. Sometimes, people just don’t know where to start. There can also be long wait times to access the right service, and we need more options for follow-up support when a patient is discharged. Finally, there is a lack of integrated services for people with dual diagnoses, such as addiction and mental health issues. This is especially true for those who do not have private insurance. There is also a real shortage of some resources such as: psychiatrists, psychiatric advanced practice providers (clinical nurse specialists, nurse practitioners, and physicians assistants are trained to treat patients with mental and substance use disorders), appropriate supportive housing, and foster care homes.
Q: What are some solutions to reducing these barriers?
A: The East Metro Round Table is looking at ways to reduce system barriers. To be successful, we need to make sure resources are used in the most cost-effective way – getting people in to the right level of care. To accomplish this, we need to develop a more integrated system that provides a continuum of mental health care.

The more we can set things up so key decision makers and players can look at where capacity doesn’t meet demand, and then redeploy resources to address gaps, the better it will work.
Q: As part of your efforts, your subcommittee developed a set of indicators.  What do they measure, and how will they be used?
A: We need to be cautious of changing systems based on anecdotal evidence alone. Metrics can validate what we’ve heard. The indicators we are looking at specifically address improving patient flow between hospitals and community services serving the east metro area. These include tracking average wait time in hospital emergency rooms and several measures to determine wait times of hospital inpatients for referrals to community-based services. These data can be used as a lead-in to talk across silos about what might work better – look at the whole continuum of care – where there is good access, where there are problems.

Q: Do you have any insights yet from the data you are collecting? 
A:  We see more people are using the emergency departments of the three hospitals where we are collecting data – Regions, St. Joseph, and United – and it’s taking longer to get help. So we need to learn if this is due to an actual increase of need or because people don’t have access to earlier interventions, such as urgent care, or a county-level crisis team.

Intensive Residential Treatment Services (IRTS) providers and hospitals reported that a major reason for delayed admission to IRTS programs from hospital inpatient care was due to lack of available bed space. So, in addition to reducing wait times for interviews to be admitted to an IRTS, we need to consider expanding the number of available IRTS beds to improve flow.
Q: Any ideas of ways to streamline the system?
A: We’ve identified a couple. Regarding patient flow, we found IRTS providers and hospitals in some disagreement about patient readiness for admission to an IRTS. So, one way to streamline the system would be for IRTS staff to develop a shared behavioral definition of when patients are ready for admission to IRTS facilities, and to identify strategies to expedite the interview process.
Regarding making it easier for consumers to navigate the system, there was a very successful pilot program in southern Minnesota. A county social worker was deployed to the hospital serving Owatonna and Steele counties. She spent most of her time in the emergency department, paying particular attention to people with mental health/CD issues that were frequent visitors. She worked with them to connect them to services, and because she was connected to the community mental health service center, she was able to streamline the process. She worked with people to arrange transportation and intensive mobile case and care management. It would be great if funding could be deployed in a sustainable way to expand this model. In fact a recent grant from the Bremer Foundation will allow us to test the use of this "in reach social worker" at Regions, St. Joseph's, and United Hospitals in the next couple of years.
In addition to his role as associate medical director of behavioral health for HealthPartners Medical Group, Michael Trangle, MD, provides psychiatric evaluation and treatment to adult and adolescent patients at HealthPartners West Clinic in St. Louis Park. Dr. Trangle has particular interests in depression, schizophrenia and other psychotic disorders, anxiety disorders, family problems, and substance abuse problems.

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Getting the Right Care at the Right Time

The Mental Health Crisis Alliance partnered with Wilder Research to explore impacts of community-based crisis stabilization services and found:

• Offering services to people while in crisis helps get them into mental health outpatient services and keeps them out of more restrictive levels of care

• Crisis stabilization improves care for consumers

• Crisis stabilization reduces costs to the system

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