People in psychiatric crisis are often stuck in emergency rooms for hours or days waiting for placement, says Ted Lutterman, senior director of government and commercial research at the NASMHPD Research Institute (NRI). In other cases, there’s nowhere for them to go. Or worse, there are openings but no systemized way to find out where.
The answer, says Lutterman, is a robust crisis continuum and a real-time comprehensive crisis services registry that helps match people to the appropriate level of services they need when they need them.
What can go wrong when people don’t have ready access to a crisis services registry happened to 24-year-old Austin “Gus” Deeds and his father, Virginia Sen. Robert Creigh Deeds, on November 19, 2013. “Gus was in crisis observation,” says Lutterman, “but the center couldn’t find him a psychiatric bed.” Under Virginia law at the time, they sent Gus home. The next day, as his father stood holding a bucket of feed for the chickens on his farm, Gus walked toward him. Father and son said good morning to one another, and then Gus stabbed his father in the head and chest 13 times before going into the house and dying of suicide.
Sen. Deeds survived the incident but wrote on Twitter just hours after UVA’s Medical Center released him, “Some wounds won’t heal.” He told The Recorder, “I cry a lot. I can’t focus now and talk to anyone.”
On the day of the attack, Dennis A. Cropper, executive director of Rockbridge Area Community Services, told the Richmond Times-Dispatch they’d been unable to find a psychiatric bed for Gus. But there were beds available, notes Lutterman, at nearby medical facilities in less than two-hour driving distance, including UVA’s Medical Center, Western State Hospital, and Sentara RMH Medical Center.
“There was no centralized system,” says Lutterman. “The community program crisis team had to call psychiatric hospitals in the state and ask, ‘Do you have a bed?’ They called a number of places but didn’t call everywhere.”
A state investigation later revealed that the mental health evaluator who handled Gus’ case did not call 27 of the 34 available facilities. Five had room to take Gus.
In response to the tragedy, Virginia passed several reforms in 2014, including a real-time bed registry—which had been in the works but didn’t come to fruition until after Gus’ death—and a bed-of-last-resort law requiring state psychiatric hospitals to provide a bed if one isn’t found before an emergency custody order expires. But shaping law around a single tragedy has pitfalls. Experts say the bed-of-last-resort law, in particular, has resulted in many unintended consequences, including increased demand on already overcrowded state hospitals and patient cherry-picking by private psychiatric hospitals, where they deny patients not because they don’t have a bed but because the patient is not acute enough or too acute.
Sen. Deeds, who championed the law, told VPM in 2019 that the law has resulted in state mental health hospitals being consistently over 90% capacity. “…there’s all sorts of evidence out there suggesting anything over 85% [capacity] puts both patients and staff at risk.”
The online bed registry, which hospitals have to update at least once a day, is far from the real-time language mandated by Virginia legislation. Still, notes Lutterman, someone at a community service board crisis program can log in and locate where there are openings. “This is the minimum states need to prevent similar tragedies and psychiatric boarding or having people stuck in jail waiting for a psychiatric bed.”
In 2016, to further the use of registries in states, the United States Congress passed the 21st Century Cures Act. The act allows SAMHSA to fund states’ development of real-time psychiatric bed registries to improve timely access to mental health treatment. Of course, everything takes time, notes Lutterman, and for several years there was no appropriation. “Without dedicated funds from Congress, it took SAMHSA two years to come up with the money.” The agency then distributed the grant through NASMHPD, providing funding for 23 states to establish or expand a crisis bed registry.
“What’s been gratifying,” says Lutterman, “is that many of the states taking part are expanding beyond an online psychiatric bed database and fleshing out the registry as a component of their crisis continuum.”
Some participating states have expanded their online database into a real-time comprehensive crisis services registry that includes community-based care. This is where Lutterman hopes all states will trend. “A registry that tracks a continuum of service placements is a vital tool to keep people in the community and divert them from unnecessary hospitalizations.” Contrarily, he says a bed registry inherently emphasizes hospitalization.
“When a registry only focuses on beds, that’s likely where people will end up,” says Lutterman.
Some states, like Georgia, have expanded their existing registry to include crisis receiving and 72-hour crisis residential program availability and reconnect people in crisis with their community treatment team. “What the person may need,” says Lutterman, “is someone to be with them for a couple of hours to make sure they’re safe, schedule an appointment for later in the day or the next day, and link them back with their program.”
A robust state registry not only helps match people to services, says Lutterman, it also tracks metrics and highlights bottlenecks happening in its psychiatric crisis system’s circulation such as capacity issues, efficiency, and staff and bed shortages.
The COVID-19 pandemic has affected the development of the state registries differently, with some states experiencing implementation or expansion delays. “The disaster has impacted every state crisis system,” says Lutterman, “but not in the same way.” Depending on the community, outpatient treatment centers and mobile crisis teams might be minimized or deactivated during parts of the pandemic, resulting in increased demands on open facilities. Hospitals, too, have experienced changes, with some halting psychiatric admissions. Lutterman says the pandemic has made it even more critical that states have a comprehensive real-time registry that reflects ongoing changes in availability.
“Some state psychiatric hospitals have had to restrict admissions because of physical distancing requirements,” he says, “while others experienced increases because nearby general hospitals closed their psychiatric units to focus on people ill with the virus.”
Lutterman says several states have added COVID-19 elements to their registry, including available psychiatric quarantine or isolation beds. They’ve reported that having an existing automated bed registry infrastructure made integrating COVID-19 tracking elements far easier. They’ve been able to adjust the registry as needs have emerged and shifted.
“These states quickly realized they weren’t just being asked if they have a bed for a 21-year-old female with Schizophrenia, for example, but who was also exposed to the virus and needed to be in an isolation unit.”
There is variation, notes Lutterman, on what real-time means. Some states use software like OpenBeds, a cloud-based platform that allows for up-to-date treatment services availability and digital referrals, while others depend on facilities manually entering the information twice a day into a centralized system. What really makes a registry work, though, says Lutterman, is when people from the crisis system and overall healthcare system at large want to take part, including hospitals and other providers who actively update information about service availability.
“It’s not programming or software that’s the impediment,” he says. “It’s getting people to be willing to spend the time to update it, use it, and understand how it’s going to help save lives.”
NRI recently released its 2020 state profiles report on the impact of COVID-19 on state mental health services. Take a look here.
Graphic by Rin Koenig