Psychiatric Help Scarce for in-Peril Local Kids
By Josh Brodesky, The Arizona Daily Star, Tucson
Jun. 5–At the beginning of the Memorial Day weekend, just as most folks were gearing up for the holiday, a teenage boy was checked into Tucson Medical Center’s emergency room after attempting suicide.
Ideally, he should have been placed in a high-level psychiatric bed where he would begin receiving around-the-clock treatment. Instead he went into a holding pattern at TMC until late Sunday when he was finally placed in a psychiatric bed in Phoenix.
It is a story playing out with increasing frequency for many of Southern Arizona’s most vulnerable youths — those struggling with severe mental illness who often have threatened or attempted suicide — waiting, only to be placed in an out-of-town hospital because of a severe shortage of juvenile psychiatric beds.
The shortage is statewide, and beyond, but it’s particularly pronounced in Southern Arizona since TMC converted one of its youth psychiatric units to treat adults.
As a result, a number of the most troubled youths are not getting into treatment for days, and in some extreme cases, they are waiting a week to get to a bed. Until then, many wait in ERs under basic care.
Though such lengthy waits are still more exception than rule, they have occurred enough times that behavioral-health workers have been searching out of state for beds where they could place Tucson kids who are critically in need of treatment.
“You have kids in emergency departments for a few days, in a bed of course, but that’s obviously not where they need to be,” said Neal Cash, president and CEO of the Community Partnership of Southern Arizona, which is the region’s behavioral-health authority.
“We have called Southern California, we’ve called New Mexico, I believe Colorado; and these states are experiencing the same thing.”
There are many different types of psychiatric settings. A level-one ward is for people with the most intense mental-health needs in a time of crisis.
They are locked, secure settings in which patients are watched at all times. People who end up in level-one wards are a danger to themselves or others.
A typical stay for youths in a level-one setting lasts about eight days before they either go home or move on to a less- intensive setting.
Southern Arizona has been short on level-one beds for at least several years. The shortage for kids became more pronounced in the last year after TMC closed its 10-bed, level-one unit to offer more beds for adults. That left the region with just Sonora Behavioral Health Hospital, which has 22 level-one beds for youths.
“They don’t have adequate capacity,” said Carol Punske, an assistant program manager for Child Protective Services in Pima County. “Most of the time, there are enough beds, but there have been times when there haven’t been enough beds for children needing in-patient psychiatric care.”
The shortage can have a ripple effect for CPS workers, who have to wait with CPS kids in the emergency rooms. Such waits can cost the department overtime or keep workers from other duties.
“We would not delay responding to a report of abuse or neglect or anything related to child safety to stay with a child,” Punske wrote in an e-mail. “But we may reschedule routine matters such as a professional meeting.”
Though Sonora has 22 beds available, only a portion of them are reserved for Southern Arizona children.
Community Partnership of Southern Arizona reserves eight beds with Sonora but will be increasing that number to 10 beginning July 1.
The rest of the beds are available to kids from outside the region who have private health insurance or belong to a different behavioral-health network.
“We accept from all over the state,” said Brian Gill, CEO of Sonora Behavioral Health. “We are only one of four hospitals that treat adolescents in the state, and one of three that treat children 12 and younger.”
The squeeze gets even tighter when age and gender are considered. Boys and girls are separated, as are adolescents and children 12 and younger. So, there might be a situation in which Sonora has room for two female children but has a waiting list of three male teenagers.
To help deal with the issue, Sonora recently received permission from the state to switch a 10-bed unit that normally serves adults to kids if there is an overflow.
So far that hasn’t happened, Gill said, because there haven’t been enough kids waiting to fill the unit while there have been plenty of adults.
Adults are one of the major reasons children are finding themselves waiting for days to get beds. There are far more adults who need level-one beds than youths who do. TMC stopped providing beds to youths because of the staggering need among adults.
“We were holding many adult patients in our emergency department,” said Julia Strange, spokeswoman for Tucson Medical Center.
“We had as many as 13 a day. That’s not a good situation for our emergency department. It’s not a very good situation for the patient.”
Census counts from CPSA patients show on any given day about 115 adults will be using level-one beds in Pima County, but only about 10 youth patients will be in need of such beds. And for the entirety of last fiscal year, 530 youth patients from CPSA were admitted to level-one wards.
Because of those numbers, Cash and others said there is little incentive for hospitals to open up more level-one beds for youths. For example, there are no youth level-one beds included in the plans for a psychiatric facility at the University Physicians Healthcare Hospital at Kino.
“This is a very vulnerable population, and obviously, the numbers are not great,” Cash said. “But when there is a need, you need to have access to that level of care.
“When you look around, and you see hospital expansion, you see very little expansion for children. UPH won’t have psychiatric beds for kids. Hospitals would probably say it is not cost-effective to dedicate these kinds of services.”
Dan Ranieri, president and CEO of La Frontera Center, said, “It’s a tough business to be in. … The margins are going to be low, if there are margins at all, and staffing, you have to balance that staffing with what your daily census is.”
So with no new beds on the horizon, the behavioral-health community has been getting creative in dealing with the issue.
At Pantano Behavioral Health Services, which provides care for youths, workers are trying to provide more in-home services to avoid a crisis arising that would lead to a hospitalization.
“We are trying to head it off at the pass, which is actually clinically the best practice anyway,” said Dr. Deborah Fernandez-Turner, Pantano’s medical director. “So, when we start to see some individual with deteriorating symptoms, that’s when we bring in a highly trained staff that goes into the school or home.”
Cash said, in addition to increasing the number of level-one beds CPSA is reserving, he also plans to reserve several beds in a less-restrictive, level-two setting, to which youths can step down.
Such a setting, coupled with the possible use of other short-term beds at UPH, could give the system some flexibility.
Though acknowledging these are all helpful options, Punske, the assistant program manager at CPS, noted they still don’t address the bed shortage head-on.
“The best practice is that you always place the child in the least-restrictive setting,” she said. “So, if the child’s needs were fully met in a lower level of care, we wouldn’t be looking for hospitalization.
“There is no alternative to level one. … If a mental-health professional has decided that a child needs to be hospitalized, you really can’t say there is another alternative to that.”
–Contact reporter Josh Brodesky at 807-7789 or jbrodesky@azstarnet.com.
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