New Minnesota law pushes mental health system to a crisis point

Hundreds of people with severe mental illnesses are languishing for weeks or even months without proper medical treatment, in part because of a law that requires state psychiatric facilities to admit some jail inmates ahead of hospital patients, regardless of clinical need or cost.

The longer waits for mental health beds are an unintended consequence of 2013 legislation that was designed to shrink the swelling population of mentally ill people housed in county jails. The law, known as the "48-hour rule," required inmates to be transferred to a state psychiatric facility within 48 hours after being committed by a state judge.

Though the rule was hailed by law enforcement officials, it has raised safety concerns in hospitals. By enabling some jailed inmates to jump ahead of hospital patients, the law means more mentally ill and violent patients are being kept longer in hospitals where staff are less prepared to deal with possible flare-ups, hospital administrators say.

Pushed to the breaking point, state and county officials are now considering some unorthodox reforms to reduce the backlog of mental health cases, such as diverting people suffering from mental health emergencies away from jails or hospitals and into smaller, residential facilities.

"There is a severe lack of flow in the system," said Dr. Michael Trangle, associate medical director for behavioral health at HealthPartners, which owns Regions Hospital in St. Paul. "It's like a water cycle. If you dam it up anywhere, then [patients] pool earlier … and the places where they pool are in jails and emergency rooms."

In 2013, lawmakers embraced the 48-hour rule as one solution to concerns that the state's county jails had become de facto holding pens for people with mental illnesses. Both the House and Senate passed the bill unanimously.

With their psychiatric disorders left untreated, some jail inmates were lashing out violently. In 2012, a Hennepin County inmate stabbed himself in both eyes after being held in the county jail for 40 days without proper psychiatric care. Another inmate broke his neck after repeatedly smashing his head into a toilet. About one-third of the inmates at Hennepin County jail suffer from a mental illness, county officials estimate.

A goal of the 48-hour law was to transfer mentally ill inmates to secure state hospitals, where they can be closely monitored and given proper medication, before they hurt themselves or others in jails. So far, 104 jail inmates with mental illnesses have been transferred to state psychiatric facilities since the 48-hour rule went into effect in July 2013, according to state data.

"It's had an enormous impact," said state Sen. Julianne Ortman, R-Chanhassen, who authored the legislation. "No one wants to see a loved one or a friend or neighbor in a jail without the treatment they deserve."

But the 48-hour rule has had some unintended consequences.

The law enables some inmates who are deemed by the courts to be mentally ill to be admitted ahead of hospital patients who may have been waiting weeks or months to get proper treatment. State psychiatric facilities, such as the Minnesota Security Hospital in St. Peter and Anoka-Metro Regional Treatment Center, are now required by law to admit committed inmates first, even if a hospital patient with more severe mental health needs has been waiting months.

The 104 admissions from jails, though not huge in absolute numbers, pose a significant challenge for a state mental health system that has just 800 psychiatric beds and already suffers from severe patient-flow bottlenecks, say hospital officials. Mentally ill patients at HCMC, which has 102 psychiatric beds, are waiting up to two months for beds at state facilities. "There has been a ripple effect throughout the whole system," said Megen Cullen, HCMC director of behavioral health.

At Allina Health, which owns Abbott Northwestern and 11 other hospitals statewide, mentally ill patients are now waiting up to six weeks for a bed at Anoka-Metro — the state's main facility for psychiatrically complex cases. Often, just days before being admitted, patients learn they will have to wait even longer because a jail inmate has jumped ahead of them under the 48-hour rule, said Dr. Paul Goering, a lead psychiatrist at Allina. The average wait for admission to Anoka-Metro has grown from 19 days in 2010 to 30 days in 2013, state data shows.

The longer wait times for admission to state facilities mean hospitals are keeping more mentally ill patients who are prone to violent outbursts. "We have a great security team … but they are really tasked to try to manage those individuals who may be grossly psychotic," said Dr. Ian Heath, medical director of inpatient psychiatry at HCMC.

Another concern is that local authorities now have an incentive to criminalize people with mental illnesses in order to get them into a state mental hospital. Deputy Human Services Commissioner Anne Barry said her office has received anecdotal reports of counties moving to arrest and jail people so they will be on a faster path to Anoka-Metro.

"[The law] sets up some perverse incentives," said Dr. Goering of Allina Health.

However, law enforcement officials say criticism of the 48-hour rule is misplaced. The long waits at the few remaining state mental facilities are just a symptom of broader failings that began with the deinstitutionalization of mental health treatment decades ago, county officials argue. Jails became inundated with mentally ill inmates because state and local authorities failed to step in and provide adequate housing and therapeutic services after closing mental hospitals.

The problem, they argue, is not the 48-hour rule, but a systemwide shortage of beds and community health options. Currently, county officials are charged with steering thousands of people with serious mental illnesses primarily through just two institutions — Anoka-Metro and the Minnesota Security Hospital.

"We need to look at this from a more holistic perspective," said Hennepin County Sheriff Rich Stanek, one of the most outspoken proponents of the 48-hour rule. "Having just [the Security Hospital in] St. Peter or just Anoka [Metro] is not, is not, is not, is not enough."

State officials are looking outside the state for possible solutions. One approach, being tried in San Antonio, Texas, involves taking people suffering from mental illnesses out of jails and hospitals and placing them in smaller, 16-bed psychiatric units. Police in San Antonio are also required to undergo a 40-hour course on how to handle people undergoing a mental health ­emergency.

Barry, the Department of Human Services deputy commissioner, said the state is examining the "San Antonio model," among other approaches. This summer, DHS convened a series of meetings across the state to discuss ideas for improving the mental health system.

"We all have to work together, and put aside what we want for ourselves, and ask what is the best for the system as a whole," Barry said. "If you just try to change one part of the system, it has an impact on the rest."

Chris Serres • 612-673-4308 Twitter: @chrisserres