Minnesota mental health patients stay 25 hours longer than necessary in ER because of shortages

When patients in mental health crises get stuck in Minnesota's emergency rooms, they stay 25 hours longer on average than necessary—taking up hospital space as well as the time of doctors and nurses, who could otherwise focus on the next emergencies.

Researchers documented the length of these delays by studying patient activity over 14 days last fall at more than 30 Minnesota hospitals, but they also provided vital evidence about which patients were most likely to suffer delays, and why.

Knowing which patients are at risk can help the state come up with treatments that target this population and prevent mental health crises and hospital visits, said Kristin Dillon, a co-author from Wilder Research, which released the report with the Minnesota Department of Health.

Delays for patients "in a hospital setting when they can be discharged is harmful to patients, caregivers, hospital staff and the health care system," she said. "However, we cannot take steps to effectively address these discharge delays without understanding the underlying reasons behind the delays."

Monday's findings were presented to an advisory council created last year to reduce delays in care and the worsening problem of ER and hospital overcrowding in Minnesota.

Staffing and bed shortages at nursing homes and rehabilitation centers have worsened since the COVID-19 pandemic, leaving hospitals stuck with frail, elderly patients on their inpatient floors. Twin Cities ERs have treated patients in hallway gurneys at peak times when they have run out of beds. But these delays in many ways compounded the longstanding problem of patients in mental health crises being boarded in ERs with nowhere to go.

Hospital inpatient psychiatric units were largely full during the study, and they couldn't take new patients from ERs until they found space to discharge their existing patients to residential or outpatient treatment programs. The study observed 182 patients in hospital psychiatric units whose discharges were delayed, and on average it took eight days longer than necessary to move them.

The problem was more complex than patients waiting for openings in treatment programs, though. One in five patients stuck in inpatient units was delayed by court decisions over civil commitments, or decisions over their eligibility for insurance benefits or waiver programs, the study showed.

Among patients stuck in ERs, only six in 10 needed inpatient hospital care. The rest were stuck for other reasons, including delays in arranging transportation home or in getting outpatient care lined up. A third of the delayed patients went straight home from the ERs.

M Health Fairview has been confronting the problem, opening a so-called EmPATH unit at its hospital in Edina that provides a relaxed environment and transitional care for patients who can be moved from the ER. The health system is also partnering with for-profit Acadia Healthcare to reopen the Bethesda Hospital campus in St. Paul as a psychiatric facility next year.

In some ways, the delays published in the report underestimated the problem. Delays were only calculated for patients who were discharged during the two-week study. About 5% of the ER patients had yet to be discharged by the end, and some spent the entire two weeks in care. Some hospitals have endured extreme cases, such as the boarding of a child with behavioral problems for months at Ridgeview Medical Center in Waconia.

State lawmakers were so concerned by the delays in 2022 that they waived Minnesota's hospital construction moratorium through 2027 for any provider looking to add psychiatric capacity. However, the study makes it clear that the greatest need is in community and preventive treatment programs that keep people from crises, said Dr. Will Nicholson, vice president of medical affairs for Fairview's East Metro hospitals.

"We can take better care of people when we can prevent illness, we can get upstream," he said.

Minnesota has been locked for two decades in a chicken-egg debate about whether to spend limited dollars on more inpatient beds, or preventive programs to try to reduce the need for those beds. State health economists blocked a proposal in 2008 by then-named Prairie St. John's to build a psychiatric hospital in Woodbury, based largely on the argument that prevention programs were more needed. The provider later became known as PrairieCare and built and expanded a pediatric psychiatric hospital in Brooklyn Park.

More beds aren't the only solution at a time of workforce shortages, said Sue Abderholden, who directs the Minnesota chapter of the National Alliance on Mental Illness. Minnesota previously tackled the mental health treatment shortage by creating a stepdown level of care called intensive residential treatment services to ease the pressure on hospitals. The state has about 60 of them operating, but many can't find enough staff and are operating well below their 16-bed capacities, she said.

The legislature this year OK'd funding for counselors who could check on patients who were showing the first signs of struggling—perhaps by skipping medication doses or appointments, Abderholden said. "We're trying to get way before a crisis, before you need an ER, before you need a crisis team."

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