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Crow Wing County Board: County feels squeeze on mental health costs

Crow Wing County officials say a state mandate is costing county taxpayers tens of thousands of dollars in avoidable costs for mental health care. Community Services Director Kara Terry and Tami Lueck, adult services supervisor, told the county b...

Anoka-Metro Regional Treatment Center is state-licensed psychiatric hospital. Crow Wing County is facing a budget shortfall for its expenditures associated with the cost of mental health care for county residents at the treatment center. Screenshot from Google Street View
Anoka-Metro Regional Treatment Center is state-licensed psychiatric hospital. Crow Wing County is facing a budget shortfall for its expenditures associated with the cost of mental health care for county residents at the treatment center. Screenshot from Google Street View

Crow Wing County officials say a state mandate is costing county taxpayers tens of thousands of dollars in avoidable costs for mental health care.

Community Services Director Kara Terry and Tami Lueck, adult services supervisor, told the county board Tuesday to expect an overrun in the department's 2016 budget and a request for a budget increase next year.

A factor driving the increased expenses is a cost shift approved by the state Legislature in 2015, which made Minnesota counties fully responsible for a cost once shared with the state. That cost is derived from the care for patients at Anoka-Metro Regional Treatment Center who no longer meet medical criteria for facility-level care.

The state-licensed psychiatric hospital is one of the facilities where Crow Wing County residents are placed when in need of hospitalization for mental health care. Once Anoka staff determine a patient no longer meets the medical need to stay at the facility, the meter starts running for the county of residence-even though, Lueck said, it's often seven to 10 days before notification of the change in patient status is received.

At $1,309 per day for care, the costs add up quickly. Eight patients from Crow Wing County were receiving treatment in Anoka between July 2015 and June 2016. Of those, six were discharged for no longer meeting medical need. The quickest discharge took a week, while the longest discharge took 62 days. That lengthy discharge time alone cost county taxpayers $81,158.

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County Administrator Tim Houle asked Lueck to explain why these patients were remaining in the facility when they no longer needed care there. Lueck said this was a question community services staff presented to the Anoka hospital as well, requesting a written explanation for the lapse of time.

Reasons offered included transportation challenges, time needed to determine where a patient will go once they are discharged and time needed to coordinate physical examinations and order medications.

Lueck said the county begins working on a discharge plan as soon as a patient is hospitalized, a plan that can include placement in a transitional facility and scheduling psychiatric appointments. In the case of two county patients, these plans were in place and the discharges still took seven days in one case and 26 days in another.

Lueck successfully challenged the state in the case of another patient, reducing the costs to the county from 76 days of care to 31 days. In that case, the patient care was deemed medically unnecessary but the hospital would not discharge the patient-because they needed medical care, Lueck said.

"The person had some medical issues, not mental health (related)," Lueck said. "The different options that we gave, they did not support that person being discharged. ... How can you tell us that he doesn't meet medical necessity if you won't discharge with these other plans?"

Commissioner Paul Koering asked Lueck what would happen if Crow Wing County refused to pay the state for those days of care.

"If we do not pay, they will start to deduct it from the payments that we get," Lueck said.

Increase in Anoka facility use

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The cost shift alone is not the only problem Lueck sees with the situation. She told commissioners more mental health patients are sent to the Anoka hospital than once were. At one time, the large facility was typically used for patients who had higher behavioral needs and were more medically fragile, she said.

Patients that once would have likely gone to community behavioral health hospitals-such as the one in Baxter-are going to the larger facility instead, in part because of a lack of available beds, Lueck said. Of 16 beds at the CBHH in Baxter, just 10 are available for use due to a lack of staff resources at the hospital.

"The state is not funding the CBHHs to the level of their bed capacity with staff," said Houle. "They shut the state hospitals locally down, looking for community-based alternatives, and now they are not funding it to the level of their own bed capacity. We're left then with our residents in Anoka past the time it's medically necessary for them to be there."

Commissioner Rosemary Franzen, who serves on the CBHH advisory committee in Baxter, said when the state was shifting mental health care to the smaller community facilities, they made promises about the system that are not the practice.

"They don't allow us to treat our people. ... We still have to take the person from another county because they're first on the list," Franzen said. "That's not how they were sold to us."

It is true, Lueck said, that those determined in the most need for a psychiatric bed will be assigned to the next one available, no matter where it is in the state. Some are even sent to facilities outside the state to meet the need, she said.

And that's partly the problem driving increased costs, from Lueck's perspective. If more patients were able to stay closer to home, it would not only provide better access to friends and family, but might also alleviate some of the logistical issues community services staff encounter. This could include the lengthy discharge times, Lueck said in a later phone interview.

Counties are bracing for another source of strain on budgets, as the Legislature added a new cost shift in 2016. This measure shifted the cost of patients who no longer meet medical need for facility-level care at CBHHs, the daily cost of which is even higher than costs at Anoka.

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Lueck said in conversations with those involved in the mental health system, she's learned Crow Wing County's woes are actually quite inconsequential in comparison to other counties. In some cases, patients were not discharged for as many as 180 days, which equates to more than a quarter of a million dollars in unnecessary care for one patient.

Solutions and prevention

Lueck said in her opinion, the problem might not be as exacerbated if both the state and the county had mutual responsibility for the costs. A similar argument was made from the state perspective in 2013 by DHS, when Gov. Mark Dayton proposed increasing the cost share from 50 percent to 75 percent for those no longer needing medical care at Anoka.

"Counties play a crucial role in placing patients who have progressed in state treatment facilities into less restrictive community settings," a memo stated. "The delay in moving these patients into appropriate placements creates a backup in the state's mental health system, making it more difficult for state facilities to serve new patients with behavioral health needs."

The increase in share, according to the DHS, was supposed to offer counties a "financial incentive to support appropriate community-based placements for patients who have advanced through state treatment."

Lueck said an interesting side effect of the increased costs to counties was more revenue for the state, which could lead to the reopening of currently unavailable beds at community-based facilities.

The county commissioners wanted to know: what recourse do counties have to prevent impacts on their own budgets from decisions seemingly outside of their control?

"I can't believe people haven't just risen up and said forget it," said Commissioner Rachel Reabe Nystrom.

Commissioner Paul Thiede suggested rather than budgeting more for these costs, this could be used as an opportunity to send a message to the state government.

"Maybe we ought to run a deficit in this program," Thiede said. "Maybe that would then give the state another bit of incentive."

"I doubt they care whether we meet our fund balance," Houle responded.

Houle said one possible way of addressing the problem was to pursue a writ of mandamus, which is a court action compelling a governmental body or official to do what's required by law.

"If we have a discharge plan in place, and we have alternatives, and they are not discharging, then we file a writ of mandamus," Houle said. "If there are legislative or rule requirements in place, then I think you can file."

Houle said staff may consult the county attorney's office on using this tool.

"It's just bureaucracy," Koering said. "They really don't have to answer to anybody, so they don't really care."

Houle said most likely, the best way to address the concerns of Minnesota counties was through local legislators pursuing a change in law. Working with county associations, such as the Association of Minnesota Counties and the Minnesota Inter-County Association, could also bring attention to the issue at the state government level.

In April, Dayton issued an executive order organizing the Governor's Task Force on Mental Health. This task force could also offer the opportunity to bring to light some of the concerns of counties in the delivery of mental health care, Terry said. Ramsey County Commissioner Jim McDonough, who is also on the board of directors for the Association of Minnesota Counties, represents the interest of counties on the task force.

In the meantime, Lueck said the county is working on ways to prevent hospitalization when it's not needed. This includes mobile crisis outreach in Cass, Aitkin, Crow Wing, Wadena, Todd and Morrison counties. This service offers crisis assessment and intervention and connects people to services they might need before a situation worsens.

Another response to prevent state hospitalization comes in when a patient probably should have been delivered to a state facility, but was unable to due to a lack of beds. In this example, Lueck said the patient is likely at the Grace Unit at Essentia Health-St. Joseph's Medical Center, waiting for a bed. In the meantime, however, they are improving, lessening the need for state services. Lueck said in these cases, social workers from the state have agreed to a discharge plan for these patients, preventing involvement of the state facilities in the first place.

"We really want to work to get them back to the community as quickly as we can in an appropriate and safe way, get them back connected to their families or the services they've been utilizing," Lueck said. "I think that's what's been so difficult."

Chelsey Perkins is the community editor of the Brainerd Dispatch. A lakes area native, Perkins joined the Dispatch staff in 2014. She is the Crow Wing County government beat reporter and the producer and primary host of the "Brainerd Dispatch Minute" podcast.
Reach her at chelsey.perkins@brainerddispatch.com or at 218-855-5874 and find @DispatchChelsey on Facebook, Twitter and Instagram.
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