Experts say Holy Cross Hospital's mental health unit beats ER or jail

Reprinted from Chicago Tribune By Dawn Rhodes
Published: May 31, 2016

Southwest Side facility treats patients in crisis

A mental health worker watches over patients in the crisis stabilization unit at Holy Cross Hospital in the city's Chicago Lawn community

Photo: John J. Kim/Chicago Tribune

A mental health worker watches over patients in the crisis stabilization unit at Holy Cross Hospital in the city's Chicago Lawn community. (

Laverne cut her wrists. She was upset and depressed. She knew she needed help.

Paramedics took her to Holy Cross Hospital on Chicago's Southwest Side. Inside the emergency room, Laverne waited. And waited.

It would be a full day before she could be transferred to an inpatient psychiatric facility in Forest Park — 13 miles from her home — and get the treatment she needed.

“It was frustrating,” Laverne said, recalling her experience from two years ago. Laverne, who asked that her last name not be used, has dealt with bipolar disorder
and depression with anxiety. “It made me more depressed than I was.”

Mental health experts say Laverne's experience is common for patients in distress. In a psychiatric crisis, two things usually happen: Patients are shuttled to an emergency room, or someone calls the police and that person is carted off to jail.

So in the past year, Holy Cross has tried a new approach with an isolated, 24-hour division treating psychiatric emergencies.

“The key was to get the patient out of an emergency room environment and into a therapeutic environment as soon as possible,” said David Martucci, a registered

nurse who manages the new unit at Holy Cross. “An ER is designed to save lives. It's not really meant to provide those kinds of therapeutic experiences our patients require.”

The hospital plans to collaborate with the Cook County sheriff's office and Chicago Police Department so officers can also bring nonviolent offenders needing urgent mental health treatment to their crisis stabilization unit, instead of putting them in jail.

Advocates say they support efforts to provide immediate, targeted treatment for people in psychiatric crisis but maintain that such services paper over chasms in behavioral health care nationwide.

“I think it's a good step toward getting people away from the jails and the prisons and criminal justice system,” said Paul Gionfriddo, president and CEO of Mental Health America. “The right step in the longer run is to try to figure out a better way of integrating behavioral health services into all health care settings — not just emergency departments.”

Holy Cross, part of the Sinai Health System, launched the crisis stabilization unit Experts say Holy Cross Hospital's mental health unit beats ER or jail City in July 2015.

Here's how it works: In a mental health crisis, an ER physician first evaluates patients for physical problems. Once they're cleared, a psychiatric-trained crisis nurse assesses patients and, if needed, transfers them to the 1,800-square-foot

crisis unit on the sixth floor. “What used to be an all-day process can be done in about an hour,” crisis nurse Robyn Avejic said.

A staff member and a security guard escort patients to the secure division with double doors locked from both sides. Patients turn in their personal belongings as a safety precaution and are given scrubs to wear. Staff in the unit decide what the patient needs next. For psychiatric patients, that could include time in an intensive inpatient unit or a referral to outpatient care for long-term maintenance and preventive treatment.

In one instance, Martucci said, a Chicago police officer brought in a disoriented man found wandering near Metra tracks. A crisis nurse saw he was showing signs of psychosis and bypassed the ER wait. The nurse tracked down the man's relatives and physician and learned that he had stopped taking his medication.

The patient was treated by a crisis unit psychiatrist, had his medication restarted, underwent some inpatient care and then was connected with outpatient services through Sinai.

Another example involves a patient who was a frequent visitor to the emergency room at Holy Cross and Mount Sinai. Once the man was transferred to the crisis unit, a social worker learned he was unhappy at his group home.

“The patient acknowledged that he had been utilizing emergency resources because he felt he had no way out of his living situation,” Martucci said.

The social worker helped the patient make arrangements to live in a different group home. He has not returned to the emergency room in six months.

Experts say Holy Cross Hospital's mental health unit beats ER or jail City Martucci said the new system is helping to combat a dynamic in which overwhelmed emergency rooms were merely housing psychiatric patients.

“Essentially, it's just a patient sitting in an ER waiting to go somewhere,” Martucci said. “During that time, nothing is happening. There's nothing therapeutic, medications might be given to address anxiety or agitation. Beyond that, there's nothing happening.”

Leaders with the American College of Emergency Physicians agree they see more psychiatric patients stewing in ERs, where physicians simply do not have the resources to treat them.

“We're trained in the first stabilization stuff,” said Dr. Rebecca B. Parker, president-elect of the American College of Emergency Physicians, based in Dallas. “We all do psychiatry in medical school, we do a residency. But doing that deep assessment, making that final diagnosis that then directs all the therapy that come after that, that really needs to be done by a clinician who is also going to follow them long term. That's not part of what we do.”

Holy Cross staff has treated more than 700 patients in the crisis unit since it opened, cutting by more than half the amount of time spent in the ER, according to Sinai administrators.

Patients stay at the crisis unit for an average of 14 to 16 hours, Martucci said. Being able to start psychiatric intervention sooner also ensures a patient is notovertreated. Sinai aims to refer seven of 10 patients at the crisis unit to a less intensive level of care, when appropriate. As of April, 62 percent of patients were able to be discharged.

“A high percentage of those patients would have gone to inpatient treatment directly from the emergency department just because a physician needs to know that they're safe, that they're getting an assessment,” said Kathe Dellacecca, Sinai vice president for behavioral health.

Experts say Holy Cross Hospital's mental health unit beats ER or jail City Patients can arrive at the unit as walk-ins to the emergency room, via paramedics or with police.

Officers frequently encounter mentally ill people and can bring them to certain hospitals for voluntarily treatment. But then they must stay with a patient until he or she has been admitted — potentially removing that officer from patrol for hours, according to officials.

A crisis unit can help expedite that process. Chicago police and the sheriff's office have signed on with Holy Cross to bring in voluntary patients needing urgent mental health treatment.

“This crisis has been developing for decades, the criminalization of mental illness,” sheriff's spokesman Ben Breit said. “It's been really foisted onto the law enforcement community. Sheriff (Tom) Dart is looking to partner with anyone and everyone that can help us do right for these people.”

Removing urgent psychiatric care from emergency rooms has gained traction elsewhere in the country. The John George Psychiatric Hospital is a regional hub for urgent mental health care in part of the San Francisco Bay Area. Paramedics can medically clear patients and transport them directly to John George. Emergency doctors from 11 other hospitals also can transfer a patient to John George.

Various studies have found that mentally ill patients who go to a traditional ER face a wait time of seven to 34 hours. But a 2012 study of five of the hospitals that send patients to John George showed patients waited an average of about two hours in the ER before receiving targeted psychiatric treatment.

The Robert Young Center for Community Mental Health in the Quad Cities also launched a crisis stabilization unit inside the UnityPoint Health Trinity Rock Island emergency department in April 2015. “Not everyone needs to be admitted to the hospital. What we try to do with this is

Experts say Holy Cross Hospital's mental health unit beats ER or jail City maximize the available psychiatric beds that we do have in the region for the people who truly need an inpatient admission,” said Dennis Duke, president of the Robert Young Center.

While experts generally support offering urgent psychiatric treatment outside the emergency room, many point out that the reason such services exist is that

hospitals are compensating for the dearth of basic mental health care. The national shortage of psychiatric professionals and community outpatient clinics is so drastic that patients cannot adequately manage their conditions, advocates say. The ER often is the only treatment option.

“It's akin to if we provided no preventive care for heart attacks,” said Laura Usher,

manager of criminal justice and advocacy for the National Alliance on Mental Illness. “If we didn't screen for cholesterol or blood pressure, but instead waited until somebody had a heart attack on the street, brought them to the ER, stabilized them and then released them with no follow-up. That's kind of how our system works now.”

Holy Cross is constructing a larger crisis unit next to its ER. It is scheduled to open in February, officials said, that will include a public entrance for walk-in patients and police drop-offs. The hospital also is setting up a new, 24-bed inpatient unit, and contracting with Catholic Charities of the Archdiocese of Chicago to establish a community mental health center inside the nearby Sisters of St. Casimir building. The St. Casimir facility also would provide comprehensive day treatment on the first floor, serving about 50 adults.

Those projects are slated for completion in late summer. Once all of it is up and running, patients would be able to cycle from the crisis unit to in-depth treatment on a different floor or to less intensive therapies on the next block. Officials acknowledge it will take time to see how well the new system works.

“It's just going to require such a significant cultural change,” said Alexa James, executive director of the National Alliance on Mental Illness, Chicago. “Officers

Experts say Holy Cross Hospital's mental health unit beats ER or jail Cityneed to feel safe that they are dropping someone off ... someplace where they aresure someone is being cared for.”

But all sides agree that ERs are not the right place to dispense mental health care. “These people don't have anywhere to go, and it's not right,” said Parker, of the American College of Emergency Physicians. “We need more outpatient clinics, we need more inpatient beds. There's no substitute for that.”

cdrhodes@tribpub.com

Keywords: health, health care, Health Care in Illinois, Holy Cross Hospital, Mental health, Sinai Health System