A patient arrived at a Dallas hospital earlier this year in need of behavioral health services, but a lack of available beds meant he was sent to Texarkana—180 miles away. Since December 2017, the region has lost 282 beds, nearly a third of its inpatient behavioral health capacity. Some facilities voluntarily surrendered their licenses and others closed down amidst a storm of violations. Demand, meantime, has increased, adding pressure to emergency rooms, remaining behavioral health facilities, and hospitals all over North Texas.
As of mid-July, North Texas had about 580 licensed behavioral health beds—a disproportionately small number for the region’s size. Houston’s Harris County has nearly triple the number of beds at 1,549, and even San Antonio has 847 licensed beds. Most major public hospitals have upwards of 150 behavioral health beds, and John Peter Smith has more than 150. Parkland Hospital in Dallas County has just 20.
Since the closures, Parkland has seen 400 more patients a month for psychological services, and patients brought in by law enforcement climbed from 700 to 1,000 a month. Every 24 hours, there are up to 35 more residents who need emergency detention due to mental health problems. Parkland hospital has dedicated psych beds in its emergency department, though often times other beds from the ER are used for mental health patients. The lack of beds can cause a back-up in the psych ER that can spill over into the regular emergency department, mixing injured and sick patients with individuals with acute mental health needs who can sometimes be violent.
The lack of behavioral health funding in rural areas only adds problems in urban areas. “Many of the mental health visits to our emergency rooms in the metropolitan areas of North Texas migrate from outlying counties due to lack of resources for treatment of mental health,” says DFW Hospital Council President and CEO Steve Love.
“Johnson says increased healthcare insurance coverage for those with mental issues would improve things.”
Funding is also an issue. A 2013 Kaiser Family Foundation Study found that Texas ranked 48th amongst states in per capita mental health funding from the State Mental Health Agency. “Even though the insurance industry strives for parity with acute care payments, sometimes the impact of less reimbursement and increased expenses compresses margins in behavioral health,” Love says.
Although better funding for behavioral health facilities would improve the number of beds, increased regulations are also making it difficult for behavioral health organizations to remain profitable.
“There are challenges to meeting new regulatory requirements and raising expectations for how a hospital should function,” says Awstin Gregg, the former CEO of University Behavioral Health Hospital in Denton. “And rightfully so. But it may leave some entities behind that might not be able to keep up with citations from the accrediting bodies.”
As the county hospital, Parkland coordinates between other providers and ancillary service providers like North Texas Behavioral Health Authority (NTBHA), which assists with an extended observation unit at Parkland.
Part of that coordination comes from a quarterly meeting at NTBHA, where hospitals with psych services meet with law enforcement and coordinate how to best care for the mental health needs in the region. After mapping where the patients are coming from, they are able to better adjust to patterns and get patients placed in facilities that are closer to where they are picked up.
Dallas County Commissioner Theresa Daniel has been part of the behavioral health leadership team working with the NTBHA during her time in office, and coupled with her responsibility as part of the team overseeing the Dallas County jail, she is familiar with the pressure on mental health providers in North Texas.
Dallas County jail is the second largest mental health provider in the state, behind only the Harris County jail. When there aren’t enough behavioral health beds, facilities that aren’t equipped to handle these patients end up calling the police, further overloading a facility where as many as 50 percent of inmates suffer from mental health disorders.
“When you squeeze that balloon, people go into Irving, and Garland and Grand Prairie,” Daniel says. “The reason we created the partnership is to say it is bigger than all of us. We have got to figure out ways of working together and leveraging our resources.”
Some relief is on the way. Georgia-based Perimeter Health has purchased two former Sundance facilities in Garland and Arlington, one of which is scheduled to reopen in August. Perimeter’s goal is to invest in the employees and facilities where other operators may have cut corners. The company has invested millions in renovations to the two Sundance facilities. “If we do the right thing up front and are fully transparent, the rest takes care of itself,” says Andrew Hardin, market CEO for Perimeter Health.
The two hospitals will focus on adolescent and pediatric mental health, adding around 220 beds to North Texas. Space for play, equine, yoga, and recreational therapy as well as improved safety design work on the interior are part of the renovations on each of the 30-acre campuses. “The money up front is not because we have to,” Hardin says. “We want to do it right from opening the doors. Ten years from now, we will not be a blip on the radar.”
In addition, a partnership between the Meadows Mental Health Policy Institute, Dallas Fire-Rescue Department, Dallas Police Department, and Parkland Health & Hospital System called Rapid Integrated Group Healthcare Team (RIGHT) Care program provides a comprehensive emergency response to behavioral health emergencies. A team of officers, paramedics, and mental health professionals are specifically trained to deal with behavioral health emergencies and possibly avoid hospital or jail admissions by stabilizing the patient where they are. Additionally, a Parkland mental health professional will be stationed in the 911 call center to help deal with mental health issues.
Celeste Johnson, vice president of behavioral health at Parkland, says that the RIGHT Care program has reduced ER visits and jail drop-offs, as they are better able to treat the issue in the community, saving taxpayers money along the way. In 2018, the team responded to 2,500 mental health emergency 911 calls, with a 10 percent decline in Parkland psych ER admissions from the ZIP codes served by the team, which diverted 31 percent of their calls from jails or the hospital. “If we could replicate that all over, that would be great,” Johnson says.
There is also a need for follow up after the patients leave the hospital. “How do we connect people really well when they come to ER so they get services when they leave?” Johnson says. Extended observation, care coordinators, a connection to adequate housing, and other wrap around services, often coordinated with NTBHA, are part of the system of care used to keep people from heading back to the hospital with another mental health emergency.
Johnson says increased healthcare insurance coverage for those with mental issues would improve things, as would funding for indigent inpatient beds. Primary care and outpatient services also need more training to head off mental health issues before they become expensive hospital or jail visits. Despite the challenges, she is proud of the work of Parkland and other hospitals to deal with the region’s behavioral health challenges, and is hopeful for the future. “People are getting care,” she says. “That’s the good part.