The announced closure of First Hospital may have seemed sudden, and the promises of Commonwealth Health to help all patients reassuring. But local people who teach and work in the mental health care field say this development has been years — if not decades — in the making, likely will be hard to permanently fix, and could be “catastrophic” in the short term.
“How did we get here? It’s more than just post-COVID labor shortages, which have affected a lot of industries,” Wilkes University Associate Professor Justin Matus said. Like most businesses, mental health care has both supply and demand, and demand for this particular service has been growing.
“Inpatient mental health hospitals are intended to house folks for perhaps four to 10 days,” Geisinger’s Dawn Zieger said. After that, they either go to longer term facilities or are released into the community expecting they will get the support they need to stay well. But there aren’t enough short-term, long-term or outpatient services to handle all the cases. “We need to bolster the full continuum of care,” she said. “It’s not any one entity that can solve this.”
First Hospital handled both inpatient and outpatient clients, with critical services available 24/7 for those feeling suicidal or destructive, psychiatric nurse Kristen Cheslick said. “The closing is potentially catastrophic not only for people in crises, but also for the mental health community who are seeking appropriate resources for their patients.”
And while there are many other providers in the county, there is no facility like First Hospital. “Our local people will have to travel a further distance unless somebody buys out the hospital,” Misericordia Assistant Professor David Hage said. And even if they do get suitable referrals, it likely will not be with providers they’ve come to know. “Continuity of care is always helpful,” he said. “It’s a challenge to start with new individuals.”
“Patients built relationships with those providers. And that is likely to go away unless someone comes in and buys First Hospital,” Matus said. “If they were getting treatment and revert to self-destructive behavior, it could cause a ripple effect throughout the county.
“There are a lot of secondary and tertiary consequences.”
How we got here
In announcing the closing set for this October, Commonwealth Health cited a problem getting qualified staff, exacerbated by the impact of the COVID-19 pandemic and a security incident involving multiple patients in June. But all four interviewees said it’s more than that.
“We’ve worked to increase the demand by removing the stigma and increasing awareness about mental health.” Matus said, pointing out that, while he sits on the board of Wilkes-Barre General Hospital owned by Commonwealth Health, he was speaking as professor in the Wilkes Sidhu School of Business who specializes in health care management, administration and hospital management.
Getting more people to recognize the need for mental or behavioral services — and making it easier to connect to those services — is a big positive, he stressed. But no matter how much we want to think otherwise, “Health care is a business subject to supply and demand.” And the supply of behavioral health services has been shifting for decades.
“The trend to de-institutionalize people with mental illness and dissolve inpatient psychiatric services originally started in the 1950s and 1960s,” said Cheslick, a board certified psychiatric mental health nurse practitioner who owns SolCentered Integrative Psychiatric Care in Kingston and is part of the Wilkes Nurse Practitioner Program faculty.
“Since then, the closure of inpatient mental health hospitals steadily increased each year across the entire country. The primary goal was to treat patients in less-restrictive environments, such as community-based clinics. Although the intention was positive, this trend unfortunately resulted in evaporated inpatient mental health options.”
And the lack of inpatient beds is expected to get worse, said Zieger, associate vice president of behavioral health at Geisinger. One study projects a shortage of 130 to 300 beds in the next few years for Luzerne and Lackawanna counties.
The health care labor shortage cited by Commonwealth is real and nationwide, all agreed. COVID prompted a lot of health care workers, in particular, to consider career changes or early retirement, Cheslick said. And it can hit mental health facilities harder because of the extra stress in dealing with people who have behavioral issues that can include depression, suicidal thoughts and aggression.
“It’s a specialty” experiencing its own shortage within the shortages of health care workers, she said. “It’s almost a double whammy.”
Which means it’s important for mental health workers to look after their own mental health, Hage said. “Our mental health training teaches the importance of access self-care,” said Hage, Misericordia’s Field Director of Social Work. The institutions they work for “also have a role in that as well. Anything you could do to create more opportunities for mental health care are always positive.”
Shortages
Zieger noted Geisinger is building a new, $40 million inpatient behavioral and mental health facility in Moosic that will add 96 beds to the area, intending to serve Luzerne and Lackawanna counties. That should open in the middle of next year.
A same-sized facility is being built in Danville, and while that is intended more for patients towards the center of the state, it may provide some beds to residents from here. That is expected to open in 2024.
Geisinger is also looking for ways to increase the number of beds at existing mental health facilities in Lewistown, Bloomsburg and Danville, all of which routinely operate at capacity.
Most of that does not help patients losing services at First Hospital this fall, she conceded. In the short term, Geisinger is increasing outpatient services, looking for 25% growth by the end of this year. And about 70% of that is virtual, connecting providers and patients online or by phone. While that doesn’t help with any immediate need for inpatient beds, getting the right assistance to clients early can prevent a problem from escalating, keeping them out of longer-term facilities.
Matus and Cheslick warn that the short-term loss of First Hospital will mean an increase in psychiatric and behavioral patients coming to hospital emergency departments. That can compound the patient’s issues, Matus said.
“What could have been a smaller problem can snow ball into much more devastating and expensive consequences,” he said. Potential suicides could find themselves in the same setting of people with gunshot wounds and heart attacks. Suicidal thoughts may not be as obvious. “They may show up in urgent care or emergency rooms and not get the care they need.”
Geisinger has been trying to head that off as well, Zieger said, “building surge capacity” for mental and behavioral problems into their emergency departments, including psychiatrists and related support on staff. That can not only help, it’s becoming necessary as mental health patients spend more and more time in EDs waiting for beds to become available in filled inpatient facilities, which in turn can’t release patients due to a lack of beds in long-term facilities and a lack of outpatient support in the community.
“The local community partners must pull together to add capacity at all levels.”
Solutions
Could First Hospital stay open with the smaller staff and still provide some services? Matus doubts it.
“There is not only the thing we call economy of scale, but also the economy of scope. You can’t build half of a nuclear power plant. You can’t simply cut staff in half at a facility like First Hospital. It’s like saying we’ll have police Monday through Friday from 9 a.m. to 5 p.m. What about someone who needs help Friday at 9 p.m, or needs around-the-clock care? There is a certain critical mass you have to have to be a place like First Hospital.
The sudden closing of the hospital may prompt calls for more money to get more people trained in the field, but “you don’t just go to school for a year and qualify as a therapist, a social worker or a psychologist,” Matus said. “We have to build the pipeline. And there is a lot of competition for really smart people in other businesses.”
Geisinger has been working to do that for years by setting up social work fellowships, psychology internships, and similar efforts to encourage and support people to go into the mental and behavioral health fields.
“This would be a really good area for some legislative incentives and interventions,” Hage said. “There are things we could do on a policy level to provide supports for mental health professionals, to help retain and keep people serving local needs.
“There are public loan forgiveness programs for professionals who work for (non-profits). Perhaps expanding that to for-profit health care facilities would help. Maybe grants to help organizations and institutions hire and retain people.”
Misericordia has tried to make it easier to get needed social work and health care degrees with non-traditional hybrid learning options so adults can learn while keeping their current jobs. Similar offerings have become increasingly common in institutions of higher learning throughout the region.
Cheslick said it could help if potential health care workers were offered tuition reimbursement for needed education, especially if they were going into high-demand fields. Guaranteed job placement on graduation for a number of years could help as well.
“I suppose if the state wanted to get out the cigar box of money, given enough time, money and effort you can do anything,” Matus said. “That’s the immediate solution, but I don’t think that’s practical.”
A less expensive option would be to “do more on the prevention path,” he added. “Look at societal factors, broken homes, what are we doing in schools, what are we doing to stop bullying? What are the root causes.”
Zieger said Geisinger is part of a behavior health initiative through the Geisinger Commonwealth School of Medicine, trying to bring a wide range of stakeholders together to “formulate a community response” to growing demand for behavioral and mental health services, but it is in a very early stage.
But a definitive answer? Matus summed up the opinion of all four. “I have no immediate solution to the problem. I’m as flummoxed as the next guy. It’s nothing we’re going to solve overnight. I hope some enterprise comes in and picks up some of the slack, but it’s a problem.”