North Dakota State Hospital straining with ‘unprecedented’ demand for services from courts, jails
Consultant finds 'concerning' delays in psychiatric services for jail inmates, including those in the Cass County Jail.
BISMARCK — The years-long discussion about how to revamp the North Dakota State Hospital settled on a preliminary plan for a new facility with capacity of about 80 adult beds.
But the assumptions used to arrive at that consensus estimate have come into question as the State Hospital and eight regional human service centers are grappling with soaring demand for services.
The skyrocketing demand for behavioral health services at the State Hospital from jails and courts is straining service providers and can’t be sustained at current staffing levels, the hospital’s superintendent has warned.
Superintendent Rosalie Etherington presented a series of service demand trend lines that have spiked during the past year, possibly because of the stresses and strains from the pandemic.
“We cannot continue at this pace with current resources,” she said in a presentation on Thursday, Jan. 20, to lawmakers studying acute psychiatric treatment needs.
Behavioral health services to jail inmates doubled in 2021, Etherington said.
The state’s eight human service centers and the State Hospital in Jamestown have confronted an unprecedented increase in court demand for forensic assessments, which mushroomed almost tenfold from 14 cases at the end of 2020 to 136 at the end of 2021.
Similarly, drug court treatment cases have increased from 89 cases at the end of 2020 to 120 at the end of last year.
Referring to a series of unprecedented trends, Etherington asked, “Is this going to continue beyond the pandemic?” Her answer: it’s not yet clear.
Some courts stopped hearing cases early in the pandemic, resulting in a huge backlog of cases, including in Cass County, which have put immense pressure on jails and the behavioral health services they require, Etherington said.
“People are languishing for months without a bond hearing,” she said, stressing jail inmates.
“Their mental health is deteriorating,” Etherington said. “Something has to change.”
The state hospital is working with jails to solve problems, but a longer-term solution might be required, she added. States that have faced similar problems that they allowed to go unaddressed for years have sometimes been sued, Etherington said.
Rep. Jon Nelson, R-Rugby, chairman of the interim committee, said the “out-of-the-box” numbers stem from the pandemic, and are therefore won’t become permanent. “Things will normalize,” he said.
When estimating the need for future State Hospital beds, Etherington’s estimate of 80 beds included 12 to 14 forensic beds for patients placed by the criminal justice system. “Those numbers are now three or four years old,” Etherington said, adding that if trends continue a larger unit will be required.
“The demand for services has gone up tremendously throughout our state,” she said.
Jailers and prosecutors around the state have complained that behavioral health treatment capacity is lacking, and patients are being “warehoused” in jails — a problem confirmed by a consultant who is working with the committee.
Renee Schulte told committee members that given the many variables it will be “very far from simple” to determine the right number of state hospital beds for a range of service intensities.
Her firm, Renee Schulte Consulting, will recommend both short-term and long-term solutions to address psychiatric treatment needs.
Jails lack adequate psychiatric services, including the Cass County Jail, which has better access than most jails in the state. “That was eye-opening to us,” Schulte said, adding that the jail struggles with a backlog in services. “It was concerning. There is an obligation that needs to be fulfilled.”
The state needs to find ways for private providers to play a bigger role in serving jail populations, Schulte said. “There is a huge need and it needs to be fixed very quickly,” she said. “A lot of people’s hands appear to be tied.”
So far, her review has found a variety of obstacles that prevent patients from gaining access to services. Problems include reimbursement rates for private service providers, and a lack of a clear understanding of the role of private hospitals, Schulte said.
Demand for psychiatric beds always fluctuates, but the swings have been dramatic during the pandemic, she said.
Beds could be freed more quickly if there was better communication of when an adolescent no longer requires to be hospitalized. “We hear frequently that kids are stuck in a hospital,” Schulte said.
Some long-term care facilities have become the “default residential setting for many with mental illness,” she said, often because of bureaucratic inflexibility.
Private hospitals would be willing to expand services, but are reluctant because of high uncertainty and concerns about reimbursement rates. “There’s just a great deal of uncertainty,” Schulte said.
The consultants will explore ways to better use telepsychiatry services, especially in hospital emergency rooms and jails to help bridge the behavioral healthcare workforce, she said. Schulte’s firm also will look for ways to better promote the behavioral healthcare workforce, which has been identified as one of the primary challenges.
“It sounds like there’s going to be some major recommendations,” said Sen. Tim Mathern, D-Fargo, who said adequate time should be allowed to draft legislation resulting from the report, which will be released in draft form in early April.
Carlotta McCleary, a spokeswoman for the Mental Health Advocacy Network, presented a resolution in support of a new state hospital, along with a full continuum of services in communities to provide access to behavioral health. She also urged payments to reimburse peer support specialists, who can help fill gaps by a shortage of behavioral health professionals.