Twelve-year-old Kristine Williams has logged a lot of time in the emergency room since she was diagnosed with mental health conditions about four years ago. But she has not been treated during any of her visits.
Mostly, the Elkton girl sits and waits — for up to 24 hours a visit — as hospital staff search for appropriate care elsewhere.
Emergency room physicians and hospital officials in Maryland say they have become overwhelmed with such patients in need of treatment for mental health or substance use problems.
Emergency room visits in Maryland fell 8 percent from 2013 to 2016, but the number of patients with behavioral health problems jumped 18.5 percent. Such cases now make up roughly a quarter of all emergency visits in Maryland.
Often there are no other places for such patients to go. But most hospitals aren’t equipped to provide the services they need.
“I’d move heaven and earth and do anything to care for her,” said Patricia Williams, Kristine’s mother. “But we’re caught in a vicious cycle. If she had appropriate mental health care in the community, a lot of this could be avoided. We don’t have providers to provide continuity of care, so we end up in crisis situation.”
Emergency rooms are charged with stabilizing mental health patients before handing them off to community-based treatment. Often, however, these patients end up waiting for attention amid the noise and chaos associated with car accidents and heart attacks.
When they get attention for their immediate medical needs, hospitals say, some refuse referrals for longer-term behavioral health treatment. Hospitals know others just leave in frustration, though they can’t say how often.
The problem has been brewing for decades, as the state closed many of its public mental health facilities in an effort to deinstitutionalize care. The number of state-run psychiatric beds has dropped by nearly 80 percent since the 1980s.
While government officials, hospital administrators and insurers have pushed to provide services such as surgery outside of expensive hospital settings, health care professionals say, there’s been less effort to open behavioral health care facilities.
"For patients with mental illness, we moved them out of the hospital and straight into the street,” said Dr. Elias Shaya, senior associate executive director for behavioral health services at MedStar Health, which operates hospitals in Baltimore and across the state.
The bulk of the patients who go to emergency rooms are diagnosed with mood, anxiety and substance use disorders, according to hospital records. But several recent studies show there aren’t a lot of options for community care even when people have private health insurance, and many patients do not.
The U.S. Substance Abuse and Mental Health Services Administration found in 2015 that 88 percent of Marylanders who needed addiction treatment did not get it. The Mental Health Association of Maryland, an advocacy group, found that year that only 14 percent of psychiatrists listed on the state health exchange were accepting new patients.
The data analysis firm Milliman Inc. released a report in January that ranked Maryland among the worst states for access to cheaper in-network behavioral health treatment, and could violate federal and state laws requiring parity between medical and behavioral health services.
Researchers commissioned by the Maryland Department of Health in 2012 found that hundreds more psychiatric treatment beds were needed, depending on the level of investment in the community. In the meantime, patients wait in emergency rooms or hospital beds. There are fewer than 700 beds in the state’s nearly four dozen acute care hospitals to stabilize psychiatric patients, and the Maryland Hospital Association reports they are nearly always full.
Kristine Williams has been diagnosed with several conditions that affect her thinking and her ability to relate to others. She has been taken repeatedly to the emergency room by her mother, school administrators and caretakers. Her mother said she has been a threat to herself and others.
She goes most often to the emergency room at Union Hospital of Cecil County in Elkton, where her mother said the staff works to find treatment in Maryland or neighboring Delaware.
Hospital officials won’t comment on individual patients, but confirmed that medical and behavioral health staff assess each such patient and look for appropriate treatment elsewhere. They said they usually find it in hours, not days.
Local community providers confirmed that Kristine is getting attention, and they believe there have been improvements. Patricia Williams said she appreciates their work, but the resources that are available aren’t enough to keep her daughter out of the emergency room. She drives Kristine to a neighboring county to see a child psychiatrist monthly and also takes her to a local therapist whose care is geared to younger children.
Union Hospital officials say many mental health patients make repeated visits. Rod L. Kornrumpf, Union’s regional executive director for behavioral health, said the insufficiency of community services has led officials to explore ways to bring more providers to the rural northeast corner of the state, directly and through tele-medicine.
Other hospitals around the state say patients often wait for hours or days in uncomfortable conditions, especially for those in crisis. There can be little privacy and a lot of activity.
MedStar’s Shaya and other hospital officials say waits have lasted up to 10 days.
Hospitals say their emergency bays are often full with patients suffering mental health or substance use disorders, sometimes taking space needed for other patients.
Dr. Neil Roy is chief of the Department of Emergency Medicine at Sinai Hospital of Baltimore.
“I think there is still a dearth of psychiatric outpatient resources for a large part of the patient population,” Roy said.
The problems are not unique to Maryland, said Frankie Berger, director of advocacy for the Virginia-based Treatment Advocacy Center. But the state hasn’t done much to address them, she said.
Texas and Washington put millions of dollars more toward mental health treatment after high-profile crises brought public attention. Maryland’s moment might have come on a frigid night in January, Berger said, when a passer-by filmed video of workers from the University of Maryland Medical Center’s Midtown Campus leaving a patient suffering a mental health crisis at a bus stop wearing only a gown and socks.
“It’s bad in Maryland,” Berger said. “At some point the state is going to have to pay the piper to make mental health treatment more readily available.”
Midtown officials called the “patient dumping” an isolated incident. But local advocates believe other patients are ushered out of area hospitals too quickly without a plan.
A coalition of groups called Marylanders for Patient Rights has been pushing lawmakers for years to require more communication and specific discharge arrangements as part of a larger patients’ bill of rights. Hospitals have resisted.
Anna Palmisano, a spokeswoman for the coalition, said legislation is needed to protect “an extremely vulnerable group of consumers.”
The Maryland Hospital Association worked with a coalition of behavioral health groups and state lawmakers to win grant funding this year for crisis response efforts around the state, among other funding. That could reduce wait times, or keep people out of emergency rooms altogether.
Other efforts to expand crisis facilities have stalled. Officials have long considered turning shuttered mental hospitals into crisis centers, said Del. Bonnie Cullison, a Montgomery County Democrat on the Health and Government Operations Committee. But nothing is on the immediate horizon — “Not for lack of will,” the Montgomery County Democrat said, but “for lack of revenue.”
Baltimore might be the jurisdiction in the state with the most extensive crisis services, said Crista Taylor, president and CEO of Behavioral Health System Baltimore, which oversees the city’s services. But they are not provided overnight.
“People need care at all hours of the day and night,” Taylor said. “We need to have services when people actually need services and where people need services.”
Hospitals also are looking to act directly, said Nicole Stallings, the hospital association’s vice president of policy and data analytics. Under one proposal developed by an association task force, hospitals would screen all emergency patients for behavioral health issues, and refer patients before they are in crisis.
Hospitals in the University of Maryland Medical System have already begun screening — and doctors have been shocked by the number needing substance use treatment, Dr. Brian Browne said.
Browne, an emergency doctor and chairman of the department of emergency medicine in Maryland’s School of Medicine, said up to 80 percent of the 4,500 to 5,000 monthly patients at the University of Maryland Medical Center in downtown Baltimore are flagged for drug and alcohol problems, and a quarter need immediate care.
The emergency room now has three social workers a day handling cases, he said, but they struggle to place everyone.
“We say, ‘It’s not safe for this guy to go home and we need to keep him around,’ ” Browne said. “How many just leave? Quite a lot, I’m embarrassed to say.”
With few options, some hospitals have gone into the treatment business. MedStar Harbor Hospital opened an inpatient behavioral health center in South Baltimore last year that takes patients from its own emergency department. Anne Arundel Medical Center is building a mental health hub that includes a drug rehab center and a psychiatric day hospital. It’s planning inpatient psychiatric care that could relieve the emergency room.
When a psychiatric patient takes up a bay, chief nursing officer Barbara Jacobs said, “It can affect the whole flow in the emergency room. In the meantime, we are trying to get this patient the right care. In an emergency, they are not getting group therapy and the other services they need.”
Dr. Reginald Brown, emergency department director at Bon Secours Hospital Baltimore, says hospitals often have just one shot at getting patients treatment, so they need to provide it. The West Baltimore campus offers medication-assisted drug treatment and a direct connection to services for patients who are leaving hospital psychiatric beds.
“So many patients are lost to followup,” Brown said. “If you don’t get them while they’re there, we might not see them again in some instances until it is too late, or later when they re-present to the hospital.”
Among hospitals that don’t have psychiatric services, many turn to Towson-based Sheppard Pratt Health System, the state’s largest private provider of psychiatric treatment. It admits about 9,500 patients a year at two area hospitals. About 6,000 are referred from emergency rooms.
Kristine has been among them.
Beds for kids with autism or adults with intellectual disabilities fill up the quickest, said Bonnie Katz, Sheppard Pratt’s senior vice president of business development. Kristine Williams’ mother has found at times there is no space for her daughter.
“There are not bad actors here,” Katz said. “Everybody is following the rules and regulations and doing what they can. There are just gaps in the system.”