Diversion unit easing Minnesota's psychiatric bed crisis

The 11 patients in psychiatric crisis appeared anything but in the EmPATH unit at Southdale Hospital in Edina. Most sank into recliners and listened to music in the airy, dim room. A couple played games and read books over coffee.

Katie Lavander had doubts when she became nurse manager of the unit, wondering whether a wide-open room with a library vibe would calm patients who are manic or suicidal. But two years after M Health Fairview started diverting patients to the unit from Southdale's emergency department, she is sold.

"I worked in a typical ED for seven years," she said. "There were behavioral codes every day, multiple times per day" when nurses rushed to subdue agitated patients.

"This is the complete opposite."

Fairview leaders provided a rare look inside their EmPATH unit last week along with key statistics to support their investment. About 45% of psychiatric patients in the Southdale ER ended up in inpatient beds two years ago, but that rate declined to 18% by re-routing as many of them as possible to EmPATH.

Only 15% of patients discharged from the unit come back to the ER within 30 days, compared with 25% of psychiatric patients in the ER previously.

Minnesota hospitals continue to report overcrowding in their psychiatric units, which forces patients in crisis to wait in ERs with minimal treatment — a problem known as boarding. EmPATH is at least easing the pressure, said Lew Zeidner, Fairview's vice president of mental health and addiction services.

"We're seeing a drop in the number of mental health boarding patients," he said. "It's not zero. We only have one EmPATH. But we're seeing it coming down."

EmPATH is short for Emergency Psychiatric, Assessment, Treatment, and Healing, a concept first tried at a hospital outside San Francisco. Southdale opened its unit in March 2021, and similar units have opened at St. Cloud Hospital and Sanford Bemidji Medical Center.

Fairview is mimicking the approach within the existing ER at the University of Minnesota Medical Center, but the results aren't the same without the separate, calming unit. Patients at Southdale change from ER scrubs to their clothes and are assigned one of 15 recliners in the unit, which is filled with natural light and decorations. The nursing station and its beeps and chatter are mostly sealed behind a window.

Patients receive immediate psychiatric care, including one-on-one therapy in private rooms and twice-a-day group sessions. Many patients in the unit are suffering their first psychiatric episodes and start medication and leave with immediate outpatient appointments.

Fairview leaders have been eager to demonstrate the advantages of the unit at Southdale, a hub of emergency care for the west metro and a drop-off site when police encounter patients in crisis at the Mall of America and Minneapolis-St. Paul International Airport.

The unit opened amid controversy — three months after Fairview closed its emergency department at St. Joseph's Hospital in St. Paul. Leaders of competing hospitals publicly complained about the loss of capacity in the east metro and the sudden increase in psychiatric cases at their ERs.

Fairview later shut down St. Joseph's, which at its peak provided more than 100 inpatient psychiatric beds. The system is replacing them through a joint project with Acadia Healthcare to renovate its Bethesda campus into a psychiatric hospital, but its opening isn't expected until 2025.

Mental health leaders in Minnesota have been trying for years to create alternatives that reduce the need for inpatient beds. The Minnesota Department of Health even refused to support a new psychiatric hospital in Woodbury in 2008 on the premise that better preventive services could make it obsolete.

Solutions included a mental health unit of the St. Paul Police Department that teamed social workers with officers to defuse psychiatric crises.

Fairview's solutions beyond EmPATH include adding mental health treatments to primary care clinics and opening a transition clinic to help people with medication refills and crisis support until their next appointments.

Fairview this year has seen a 15% increase in referrals for mental health treatment.

"Post-COVID, people waited a real long time to come in and get help," said Dr. Richard Levine, Fairview's director of adult behavioral outpatient services. "We are seeing people farther down the road of no treatment or missing treatment and it takes longer to get those people feeling better."

Zeidner said a key next step is convincing insurance companies that EmPATH units pay off. Health plans have been hesitant to fund them because of their increased staffing costs compared with ERs.

"A couple days in the EmPATH, although it's more than a traditional emergency department, is much less than a stay in the hospital," he said.