Bridging the Gap

What happens when indigent mental health patients are released from in-patient care? All-too-often, after being stabilized on medication and inpatient treatment, they are released with no medication, and weeks to wait for follow-on treatment.

What follows is a predictable spiral back into the darkness, culminating in another trip to the emergency room, jail, or emergency protective custody — if they’re lucky. Is there a way to prevent this cycle, to improve outcomes for the patients, and reduce the cost and stress on over-taxed emergency rooms and police departments?

A local program in Enid, Oklahoma is working to bridge the gap between inpatient and follow-on treatment. Read more at the link, or in the full text below. What are you seeing in your community?

More than one in five Oklahomans suffer from mental illness, and roughly one in six have no medical insurance coverage.

Those figures, provided by the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) and the Oklahoma Hospital Association, respectively, underscore an ongoing effort in Enid to help mental health patients stay on their medication.

Taylor Randolph, chair of the mental health sub-committee of the Human Services Alliance (HSA) of Greater Enid, said his group has been working to bridge the gap between two levels of mental health care: emergency inpatient care and ongoing outpatient care.

“What we were seeing — it was a continuous issue that kept coming up — was people weren’t staying on their medication after they left inpatient care,” Randolph said.

Cheri Ezzell, executive director of Community Development Support Association, said that trend feeds a cycle of people falling back into crisis, requiring law enforcement and emergency medical services intervention, emergency room trips, and a return to inpatient care.

“This is the story of mental health treatment in our country in recent years,” Ezzell said. “People have to become really bad on the streets, cause a problem, and then they get institutionalized for a very short period of time, and then they’re discharged without medication and eventually end up in the same place. It’s a vicious cycle.”

The HSA and CDSA are working to break that cycle by providing low-income, uninsured patients with the mental health medication they need, to bridge the gap between inpatient care and follow-on outpatient treatment.

The need

Uninsured and indigent mental health patients in northwest Oklahoma will likely be served at some point by Northwest Center for Behavioral Health (NCBH), the regional arm of ODMHSAS — either through inpatient or outpatient care, or both.

NCBH operates an inpatient mental health facility at Fort Supply, roughly 100 miles west of Enid, as well as five satellite outpatient clinics serving 13 counties, including one in Enid.

NCBH executive director Trudy Hoffman said patients who are released from inpatient care typically are scheduled with a case manager within a few days, and with a NCBH outpatient psychiatrist for ongoing care within two weeks.

Once a patient is under the care of a psychiatrist at NCBH there are patient assistance programs to connect patients with government prescription drug programs, and she said NCBH won’t refuse prescription medication to clients due to inability to pay.

But, she said, it’s “incredibly important” the patients stay on their medication during that two week transition.

“They’ve been stabilized on that medication, and then when they’re released you want them to stay on that,” Hoffman said. “Otherwise, we’re defeating the purpose of them receiving inpatient care.

“We want to get them on their medication as soon as we can,” Hoffman said, “because if they’re not on their medication, they’re eventually going to end up back in-patient.”

Hoffman said NCBH provides patients leaving Fort Supply with two weeks of medication to hold them over until their follow-on clinic appointment.

But, in Enid, an increasing number of emergent mental health cases are being admitted through the emergency room at St. Mary’s Regional Medical Center to Resilience Behavioral Health, the hospital’s 15-bed inpatient mental health ward.

The medication gap

Dr. Jahangir Ghaznavi, medical director for Resilience Behavioral Health, said admissions to the inpatient treatment center have increased since it opened in November, 2015.

“We are seeing more patients in this area than before,” Ghaznavi said. “Since we opened, we have not been empty for a single day.”

Resilience provides inpatient care without the need for a 100-mile drive to Fort Supply. But, as a private facility, it does not discharge patients with follow-on medication.

Patients leaving Resilience inpatient care, then, must wait until they are seen at NCBH to start receiving more medication, if they do not have medical insurance or the means to purchase the medication on their own.

Craig Harling, program director for Resilience, said that wait has been driven up by a critical shortage of psychiatric care providers, especially in state programs serving indigent patients.

“There is a national crisis in psychiatric care providers,” Harling said, “and for Northwest Behavioral to be able to keep up with the demand — there’s just not enough providers.”

Harling said Resilience staff work to get patients in for follow-up care within several days of being discharged, and NCBH usually is able to get a patient in to see a case manager within that timeframe. But, he said, it may be two weeks or more before a patient can see a psychiatrist in an outpatient setting, and begin receiving follow-on medication.

And, the number of patients leaving Resilience who don’t have insurance, and who can’t afford to purchase their medication, is on the rise.

Tasha Billingslea, community education manager at Resilience, said there’s been a 5-10 percent increase over the last year in the number of patients who come in with no health insurance, and no way to pay for ongoing medication.

Billingslea said 30-40 percent of patients admitted to Resilience now have no funding source for their care, or medication.

Limited resources

CDSA is working to help those patients stay on their medication as they wait for ongoing care at NCBH, but the nonprofit has no dedicated funding source to meet the growing demand.

“We have a very small emergency assistance program for people who need help with their medication,” Ezzell said. “But, people started showing up with mental health medication needs, and we didn’t have the resources to meet it.”

Deborah Shorter, Rx for Oklahoma prescription assistance coordinator at CDSA, said the people she sees on a daily basis have few alternatives.

“Most of the people I see have no insurance coverage at all, and they’re not able to work because of the severity of their illness,” Shorter said. “We’re just helping them pay for their first set of medication, to hopefully get them to their first set of appointments.”

Ezzell said CDSA has received some funds from a local church to help with the transitional mental health medication needs, but the amount of money available is far outstripped by the need.

“They go into inpatient treatment, and while they’re there they get stabilized with the medication they need,” Ezzell said. “But then, they get discharged with no medication, and our office is working to get them their medication for several weeks while they’re waiting to be seen.

“Treatment can be very effective,” Ezzell said, “but there needs to be continuity, and the thought was ‘Let’s get them the medication they need during that gap while they’re waiting to be seen.'”

In order to help cover the need HSA voted in June to provide CDSA with $2,000 from its budget.

Ezzell said those funds have helped, but there’s no budget to continue the funding, and in one month $600 of the $2,000 has been spent.

Shorter said she works with pharmacies, drug manufacturers, and Rx for Oklahoma to procure the medications as inexpensively as possible.

“I’m trying to be a good steward of the money, but also get the clients where they need to be,” Shorter said.

So far it’s cost about $100 per client to get them through the wait time to ongoing care.

A more comprehensive approach

Ezzell said the mental health medication program is filling an emergent need — in the short term — but a more comprehensive approach, and more funding, will be needed in the long-term.

“The mental health subcommittee is trying to look at the bigger picture and make sure when people are discharged that they’re tracked and taken care of during that transition,” Ezzell said.

The HSA is working to establish a Program of Assertive Community Treatment (PACT) Team — an approach that has been widely-used in other communities to manage and track patients between inpatient and through outpatient care, to improve outcomes and reduce the need for emergent inpatient services.

For now, CDSA and HSA are working to keep the patients on their medication, as a first step in improving outcomes for indigent mental health patients in the community.

“At this point it’s kind of a band-aid,” Randolph said. “It’s not a sure thing that the resources will be there to help in the future.”

Ezzell said currently there is no funding source to replenish the program when the initial $2,000 runs out.

“We’ll try to find some more money to fund this,” Ezzell said. “We’re not funded to meet 100 percent of the community’s needs. We do what we can. As long as there’s a need and we feel like we can make a long-term difference, we’re going to look for a way to do that.”

Ezzell said CDSA does accept tax-deductible donations, and funds can be earmarked specifically for the mental health medication program. And keeping the program funded, she said, could help prevent much greater costs to the community in the future.

“There’s a cost to the community,” Ezzell said. “If someone can stay productive in the community, that’s far better and far less costly than them falling down, falling off their medication, and ending up in crisis.”

For more information on the mental health medication program, or to donate, contact Shorter or Ezzell at CDSA at (580) 242-6131.

This article originally was published in the Enid News & Eagle on July 16, 2017.

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