>>’Crisis’ necessitates expansion of SMC emergency department’s behavioral health unit

Sep. 22—Need pushes Samaritan ER to expand behavioral health

WATERTOWN — In the summer of 2022, Samaritan Medical Center’s emergency department had a stretch of 45 days straight in which its volume of behavioral health patients necessitated a diversion of those patients seeking such care.

Behavioral health patients are still stressing the limits of the emergency department, prompting SMC to undergo a $2.5 million project to expand the department.

“We needed to be able to accommodate, more safely, these behavioral health patients, both adults and children, and try to keep as many of our emergency department beds open for medical patients as well,” said Thomas H. Carman, SMC President and Chief Executive Officer.

The behavioral health “crisis” situation at SMC and its emergency department is mainly fueled by pediatric patients — classified as those up to age 17. In the past five years, SMC has seen a 25% increase in pediatric emergency department patients. From February of 2022 to June of this year, 803 children arrived at SMC’s emergency department for a behavioral health emergency.

Pediatric behavioral health crisis care is a national issue. In 2021, the U.S. Surgeon General published an advisory stating that in recent years, significant increases in certain mental health disorders in youth have been recorded, including depression, anxiety and suicidal ideation. The report says that mental health conditions can be shaped by a variety of factors: biological, including genes and brain chemistry and environmental factors, including life experiences. The COVID-19 pandemic increased rates of psychological distress among young people, the report also notes, and that the pandemic most heavily affected those who were already vulnerable.

This includes youth with disabilities, racial and ethnic minorities, LBGTQ+ youth, and other marginalized communities.

Earlier this year, the U.S. Centers for Disease Control, in its Youth Risk Behavior Survey, found alarming mental health trends among school-aged youth between 2011 and 2021, especially among teen girls.

In June, New York State Governor Kathy Hochul released findings of a Youth Listening Tour at the first-ever New York State Summit on Youth Mental Health held at the Jacob Javits Center in New York City.

Based on the findings from the tour and the discussions held at the summit, several youth recommendations emerged, including:

—Investing in community-based resources for recreation and mental wellness promotion.

—Youth-vetted training on navigating social media.

—Increased mental health resources that are free/low-cost, confidential, respectful and culturally competent.

The summer months are a slower time for pediatric patients in SMC’s emergency department, with fewer referrals from school districts helping to reduce the volume.

“But any given day, anything can happen,” said Jon LaFontaine, Lead Clinical Discharge Planner in SMC’s Emergency Department Behavioral Health Unit. “When I walked in at 7 o’clock this morning (July 6), there were three kids that were waiting to be seen, which is almost the same amount that we’ve seen through the entire month of July so far.”

SMC’s current emergency department, located in its patient pavilion, opened in 2010. “At that time, within the emergency department itself, we had a five-bed secure behavioral health unit,” Carman said.

“Secure” means a unit is locked and such rooms also have no items such as cords hanging on walls that could be a risk to patients if left unattended. Since 2010, the number of behavioral health patients steadily increased. “We actually developed a plan where when we needed to overflow, we could overflow those patients into two rooms that were just outside the secure unit that had good visibility and which we could make as safe as possible,” Carman said.

“Today, when we exceed seven patients, which we do consistently almost on a daily basis, we have to pull staff from other areas because we have behavioral health patients in rooms that are not really safe for them to be in,” said Andrew Short, SMC’s Vice President and Chief Operating Officer.

In the summer of 2022, during a significant increase of behavioral health patients at SMC’s emergency department, Carman and other hospital officials sought a solution to deal with the volume. Carman contacted Nancy Williams, director of hospital programs at the Central New York Regional Office of the State Department of Health.

“I’ve worked with Nancy over the years and brought this issue to her and started talking to her about what are some of the options we might be able to consider,” Carman said. “What kind of appetite would the department have for different things to try to address this crisis? What we really found was the need to increase capacity within the emergency department. The problem we really have is not just this growing behavioral health population, but as we have that large behavioral health population, it cuts into the rooms that we typically use for medical patients.”

Last fall, SMC further explored options and honed in on them.

“That’s when we landed upon an expansion of our emergency department that will allow us to take our five-bed secure unit and make that a 12-bed secure unit,” Carman said.

It’s an increase of seven. However, since the unit now uses two “overflow unsecure” beds, it will actually be an increase of five BHU beds.

To accomplish the expansion, an office and storage area will be removed and SMC’s Starbucks coffee shop will be relocated. Also, medical beds in the emergency department will be reduced from 31 to 29.

“We’re sort of taking the current unit and expanding it in two directions,” Short said.

In late July, SMC received word that its emergency certificate of need was approved for the emergency department’s BHU expansion. Phase 1 construction was expected to begin around Aug. 11.

“We’ve already begun to order most of the materials to do the construction,” Short said in early July. “We’re expecting an eight-to-ten-month construction project to get this done.”

Short said the project will go beyond benefiting behavioral health patients.

“When we do this expansion, we’ll have safe, secure rooms and we won’t need to pull other staff from other areas,” he said. “Those patients seeking medical care in our emergency department will be able to be seen faster, but we’ll also have those behavioral health patients in a more safe location.”

Currently in the SMC emergency department, between medical and behavioral health, there are 38 beds. That total will increase to 41 after the expansion — 29 for medical and 12 secure BHU beds.

more wait time

Of the 803 children seen at SMC’s emergency department for behavioral health between February of 2022 to June, 275 were deemed in need of hospitalization and transferred to a higher level of care.

A total of 549 patients were already established in outpatient behavioral health services in the community, while 254 patients had no behavioral health record established.

“Over the past few years, we’ve seen the length of time it takes for us to find a place to transfer behavioral health kids is now over 35 hours,” Mr. Carman said. “In the past, it was somewhere around 15 to 18 hours on average that they would be in our emergency department while our team worked on a facility to transfer those patients. On average, patients are here almost a day-and-a-half waiting for a bed somewhere, and as they’re waiting, we have other patients coming in.”

A certain percentage of those patients, adults and children, get admitted to SMC for inpatient care. The hospital has a 32-bed inpatient mental health unit.

Others can be transferred to programs in the community. SMC pediatric behavioral health patients, due to the lack of beds, are often transferred to a host of pediatric sites across the state.

“We were finding that because of our adult population and our own inpatient mental health unit being full, that we were transferring 20 percent of them as well,” Carman said. He said this “speaks to” not just a “crisis” in Jefferson County, but “frankly across the state of New York and I believe it’s across the nation as well.”

Mr. Carman said that in addition to the proposed emergency department expansion, SMC is seeking the approval to add five additional patient beds to its inpatient mental health unit.

“We’re very fortunate to have an incredibly talented team of caregivers that can treat those patients, but keep in mind that when patients come to our emergency department for mental health care, that’s generally too late. They’re already in crisis,” Short said. “The ability or inability for people or their hesitancy to get care in advance of being in a crisis at an outpatient behavioral health clinic is really what’s driving the big increase in volume.”

Behavioral/mental health patients generally don’t show up on their own, Short said.

“Some of them do, but many are brought in by the authorities either by a pick-up order where they’ve been sent from a school, a parent or a family member has brought them in. They’re generally in a crisis when they come to us, where they are either going to harm themselves or someone else.”

Christina O’Neil, Director of Mental Health Services at SMC, said that if it’s determined that a child needs a higher level of behavioral health care, officials start looking for a bed at a facility for them.

“Sometimes, that’s more difficult than others,” O’Neil said. “There’s a shortage of inpatient pediatric beds throughout the area. So, sometimes kids might have to wait a little longer than we would like to see.”

If children do not require hospitalization, they are given referrals to an outpatient clinic. “There are several outpatient clinics in the area,” O’Neil said. “They can be seen very easily upon discharge from the ER.”

O’Neil explained that all mental health clinics in the area licensed by the New York State Office of Mental Health have walk-in hours. “Anybody can be seen just by walking in and without an appointment,” she said. “Unfortunately, the general public doesn’t always know that, so they’re not always aware of that. Any community mental health clinic such as ours at Samaritan has open access for outpatient services.”

“It’s really about that proactive approach, knowing that there are walk-in appointments,” said SMC spokeswoman Leslie M. Distefano. “There are warning signals and things happening. We’re hoping that parents will take advantage of the resources in the community so that their child doesn’t present in crisis. It’s a very scary situation coming into an emergency department. But with the mental health crisis, I often think it’s even worse.”

“There was a time, many years ago, when all of these clinics had large, large waiting lists,” O’Neil said. “To jump the waiting list, people would go to the emergency room, because then, all these clinics would have to see the person upon discharge within five days. But that’s not the case anymore and there’s a large misconception out there that there’s a waiting list at these clinics. There’s not.”

O’Neil added that there is less stigma these days related to people seeking treatment for behavioral health matters.

“It’s much less with the younger population,” she said. “They’re very open and they share with their friends if they have a therapist or counselor. They’re proud that they’re getting help. I think that they’ve helped break that stigma a lot. It’s really encouraging.”

Lafontaine said that one factor helping to drive the increase in behavioral health treatment for youth at SMC is transgender issues. “There’s obviously a lot psychologically going on with those kids — the fear of the stigma associated with that, acceptance and everything that goes along with that. We are definitely seeing an increase with that population, both male-to-female and female-to-male.”

The planned behavioral health unit expansion at SMC will benefit all ages, O’Neil said. “What it’s going to do is to help free up those medical beds for medical patients because right now, we’re overflowing into the medical area and that’s compromising the medical patients as well.”

Distefano noted the 35 hours statistic — the length of time it takes for SMC to find a place to transfer behavioral health pediatric patients. “We are making sure they have that safe space in a safer environment,” she said. “It’s really important because we know that they might be with us a little longer than they were a few years ago.”

“That’s the beauty of this 12-bed expansion,” Carman said. “The safety of the patient comes first. All of the rooms will be a safer environment for them. There are no ligature risks within the rooms. This is going to be a much safer environment for our children and our adults.”

Project funding

To help fund the $2.5 million project, the Children’s Miracle Network at SMC is providing $300,000. Angie VanWormer, Children’s Miracle Network Director at SMC, said the allocation is “a large one” for CMN. “And it’s one I think the community is recognizing the importance of mental health, especially for children, is kind of easy to get behind,” she said.

Funds raised through the CMN program support child-centered areas of SMC through the funding of capital projects and purchase of critical pediatric equipment. Funds raised also provide financial assistance to local families with a child facing a medical crisis for travel expenses and other out-of-pocket medical costs — a program unique to Samaritan.

“In terms of our emergency department’s behavioral health unit with the increase of pediatric patients we’ve seen over the last few years and recognizing the area itself needed some help to be more child-friendly, appropriate and safe, we took the request to our allocations committee meeting in March and requested them to approve the $300,000,” VanWormer said. “They approved it, basically in agreement with the idea that our pediatric patients that are coming in really needed to have the space that was going to be more appropriate for them.”

VanWormer added, “Our corporate partners were very excited that we were taking this on. They’re going back and helping to raise those funds with the knowledge that they’re going to be supporting children in our community that come for services here.”

“It’s huge,” Distefano said of the CMN funding. “And I think it’s a unique ask for Children’s Miracle Network, but one that the entire allocations committee and corporate partners really saw the value in because of the uptick in need and the data that’s there with the pediatric population coming through our emergency department when they’re in a mental health crisis.”

Distefano said that often when people think of CMN, it’s a medical need or a piece of equipment that’s funded.

“This one rose to the top because of how much the service is being used by the pediatric population,” Distefano said.

Also helping to fund the project is the Samaritan Medical Center Foundation, established in 1995, which is providing $63,500.

Jefferson County Community Services is providing $430,000. “These funds are a result of the New York State Attorney General’s successful litigation with several pharmaceutical companies,” Distefano said, noting that SMC needed to apply for them.

“We will continue to look for funding sources, including grants, but most of the remaining funds will come from the operating budget, as this is very necessary,” she said.

Secure beds in the behavioral health unit at Samaritan Medical Center’s emergency department will be expanded from five units to 12. This shows a rendering of the plan. / Image courtesy King + King Architects/SMC