Behavioral Health Unlocked

It’s one of Mary Greeley’s most complex and necessary services, and it’s growing. Here’s why.

By Steve Sullivan

Melanie was brought in by a friend, but she’s been here before. Jennifer is ready to do “whatever she needs to do to get home.” Matthew is paranoid and delusional and hearing voices. He’s “nowhere near ready to go.”

And so begins another intensely focused day on Mary Greeley’s Behavioral Health Unit, where each morning a team of therapists, social workers, psychiatric nurses, nurse practitioners, and psychiatrists gather to review each patient being treated on the sixth floor of the medical center.

One patient has reportedly expressed a desire to overdose, while another isn’t sleeping or eating and “wishes someone would just shoot her.” One young woman denies being suicidal. Another hasn’t eaten in days and comes from a family with a history of eating disorders. One man is going through drug withdrawal, and the good news is that his sores are drying up.

The questions are many, and the conversation is lively. How much sleep did each patient get? What’s the next step, the next place for them? Will they go home or to another facility? What kind of support do they have? What community resources are available? Are their families a help or a hindrance? Who has Medicare? Medicaid? Private insurance? Which facility will take military insurance? The review of these fragile lives by these experienced professionals is open, honest, and occasionally touched with gentle humor. What permeates everything, though, is a commitment to help each of these patients get better.

“It’s very much a brainstorming session,” said Jody Kapustka, MSN, RN, PMHNP, a psychiatric nurse practitioner. “The goal is to come up with the best plans for our patients. We want to get their needs met outside of the hospital in a timely manner, as well as understand what needs to be done while they are here with us.”

Behavioral Health is one of Mary Greeley’s busiest and most complex departments. Access to mental health care in Iowa is a significant issue and with one of the few inpatient units in central Iowa, Mary Greeley is right in the middle of it. In this article, we will take you behind the scenes to help you understand the place, what happens there, and the people who provide care. We also offer a look at what the future of mental health care at Mary Greeley might be.

The Place

Mary Greeley’s Behavioral Health Unit is behind a locked door, which can make it intimidating. If you are a visitor, for example, you will need to pick up a phone so someone can let you in. Lockers in an anteroom are available for valuables and anything that could be a weapon. There are no guns allowed, even when law enforcement comes to the unit.

Once inside, though, you enter a space that is comfortable and quiet. There are two separate units: a 4-bed high-acuity unit and a 14-bed general unit. The area is decorated in calming beige tones and is sparsely furnished. Everything is designed for safety. You won’t find any thumb tacks in bulletin boards or glass in picture frames.

“High-acuity patients are incredibly ill and can’t tolerate the general unit. There’s too much stimulation, which can lead to undesired behaviors escalating,” said Christine Krause, director of Behavioral Health Services. “Treating these patients in a separate area creates a much safer environment for them. We are learning a lot from this environment and continue to make changes to enhance safety and quality of care.”

It is possible that someone in the high-acuity area can stabilize to the point of being shifted to the general unit, and vice versa.

The general unit bedrooms are doubles. The bathroom doors in each room have partial doors that can easily be torn from Velcro hinges in case of an emergency.

A multipurpose room provides a gathering space for patients, where they can play games, have a snack, and interact with each other and staff. Regardless of whether they are in high acuity or the general unit, behavioral health patients have opportunities to engage with others coping with mental illness.

“This can be very therapeutic,” said Krause. “Others can say, ‘Hey, I’ve been where you’re at; it gets better.’ They support and encourage each other. It helps reduce the stigma of mental illness.”

Though a locked unit, the area has the same services as other inpatient areas. Dietary staff brings meals. Guest Services staff clean rooms.

Admission and Treatment

Mary Greeley’s Behavioral Health inpatient unit treats nearly 800 adults each year. This translates to more than 4,200 patient days (the number of days those 800 patients spend in the inpatient unit). Both these statistics are trending up because mental illness does not discriminate on the basis of gender, age, or socio-economic status.

“You never know what you are going to walk into. Every day is different, every patient is different,” said Dr. Kasey Strosahl.

On any given day, patients in Mary Greeley’s Behavioral Health Unit represent a diverse mix in terms of age, gender, socio-economic background, and, of course, condition. They are highly educated and intellectually disabled. They are bipolar, manic, or schizophrenic. They have anxiety disorders. Sometimes these maladies are coupled with addiction issues. What all these people have in common is that in their current state, they are considered at risk.

“Their mental illness has decompensated to a point where they are a risk to themselves or others, either actively or passively,” she said. “Actively means they are making threats, for example. Passively means they just can’t manage their own self-care. They are not eating. Not sleeping. Not able to function. They are engaging in activities that are incredibly unsafe, like walking down the middle of the highway.”

These patients can take many paths to Mary Greeley’s inpatient unit. Some are brought by friends or family members, whereas others are transferred from other facilities. They are brought by law enforcement after being court ordered to mental health treatment. Others are admitted after first being evaluated in Mary Greeley’s Emergency Department.

Because they are brought to a locked unit, the admissions process can be overwhelming.

“We purposefully limit contact with the outside world,” Krause said. “You have to keep in mind that in a lot of cases what brought people here is the inability to cope with the outside world and the stresses that it brings with their illnesses. We keep them on the unit and limit visiting hours. We have to ask family to take a deep breath and let us get their loved one in a better place.”

Ultimately, the process is designed to be as calm and safety focused as possible, said Krause.

“When a patient arrives, we greet them and explain what the immediate process is. We take their belongings and they change into a hospital gown. We do a noninvasive body search to ensure their safety. We search belongings for contraband,” said Krause.

“The biggest thing I try to enforce with my staff is to make sure that when patients are coming onto the unit you greet them with a smile. Make sure they know who you are and what you are doing,” said Christina Mayfield, BSN, RN, unit supervisor. “New patients don’t know what to expect and it can be scary. We need to make them feel welcome and at ease with no surprises.”

Emergency Department

Mary Greeley’s Emergency Department (ED) is a safety net for behavioral health patients, said Krause. It’s often the only option for people who can’t otherwise access mental health care.

“What we really do there is determine whether someone is at risk to harm themselves or others. They clearly may not need the level of help that would require admission as a patient. In these cases, we will provide resources to seek in the community,” she said.

About two-thirds of the people who come to the ED for behavioral health-related issues are assessed and discharged with recommendations for care in the community. For the other third, admission to a mental health facility may be required. If there is space, a patient might be admitted to Mary Greeley’s unit. Otherwise, another facility will have to be located.

Mary Greeley’s ED has two rooms specially designed for mental health patients. These are staffed by psychiatric nurses. This is a big advantage, Krause said, because many hospitals don’t have trained psychiatric nurses in the ED, assessing patients and providing input to the ED physician.

If an ED physician feels it necessary, a patient can be placed on a 48-hour hold to be fully evaluated.

(Mary Greeley’s Behavioral Health Unit is for adult patients. Adult and adolescent patients are treated and evaluated in the ED.)

Assessment

When a patient arrives at the inpatient unit, nursing staff will do an assessment. They will review general and mental health, including medications the patient is taking and treatment history. They will review why the patient has been brought to the unit. The patient will be given a tour of the unit and introduced to peers.

The information gathered during the first 24 hours is critical because it will help staff formulate a treatment plan. The patient is the first source of information but not always reliable. With proper authorization, family members can help fill in gaps. Staff will try to find other records based on what the patient shares.

“You need to glean the story. One of the huge challenges for psychiatric patients is continuity and consistency of care,” said Krause. “We want to establish what their care environment has and hasn’t been. We really try to be diligent to figure out where they’ve been, what’s been going on, and what we can do to do what’s right for them. Maybe something hasn’t been working. Maybe they haven’t been compliant. So do we need to change something or start more intensive case management? It’s so important to create that patient’s story.”

Treatment

People can sometimes have antiquated ideas of mental health treatment.

“One of my patients told me, ‘I am so thankful for what you did for me. This is not what I expected. I thought you’d have me in a straitjacket,’” said Strosahl.

The treatment plans vary from patient to patient. For some, medication is the answer; for others, maybe not. The best treatment could be a combination of medication and therapy. The key is finding the best approach to stabilize a patient’s mental health crisis and working toward a discharge plan.

Depression patients, for example, typically receive the fullest range of treatment. On Mary Greeley’s inpatient unit, that means daily meetings with a psychiatrist or nurse practitioner to discuss symptoms and do therapeutic work. It can also mean group therapy sessions and recreational therapy. In some cases, treatment for depression or other conditions involves electroconvulsive therapy (ECT). This procedure is done at major hospitals, such as Mayo Clinic. Mary Greeley is one of a handful of hospitals in Iowa that offers it. Done under general anesthesia, ECT involves small electric currents passing through the brain, causing a brief seizure, which helps reset the brain’s chemicals.

“For severe depression, it can reset chemicals in the brain. It really does help some people,” said Strosahl.

Some patients’ behavior put them at such a high risk that they require 24-hour supervision. Often these patients have a history of incarceration and violent behavior. No surprise, it is difficult to find long-term facilities for these patients. Two of the state’s four mental health hospitals were closed in 2015, making placements of these patients even more challenging.

As a result, these patients may stay longer at Mary Greeley.

The average length of stay is five to six days. Some get out sooner; some stay much longer. Mostly, patients return to their communities with recommendations for follow-up with a community service. A patient without a residence may be referred to a group home, for example.

Rehospitalization

“There’s always a sense of hope when a patient significantly improves and is discharged from the hospital,” said Strosahl. “You always have a sense of concern too, wondering how effective the outpatient services will be and if it will be enough.”

It can be disappointing and frustrating for caregivers, but sometimes a patient’s treatment plan does not work. Their resources aren’t sufficient or the patient isn’t compliant. This can result in rehospitalization.

“You do get to know these folks very well, and some patients can start to feel like family. You see them again and you greet them with, ‘Oh my gosh, how are you?’” said Shannon Lindley, MSN, RN, PMHNP, a psychiatric nurse practitioner. “Their world has just crashed and they might be glad to see me, but it’s a tough situation.”

Adds Kapustka: “When a patient is discharged, we always tell them, ‘if you get to a point where you are not safe and cannot care for yourself, please come back to the hospital.’ We would rather see them here, where we can provide the care and oversight they need.”

Regional Approach

Iowa has recently established regional mental health systems to help ensure community-based continuums of care.

“Compared to 99 counties having their own system, a logical person can see the value in this approach,” said Brian Dieter, president and CEO of Mary Greeley. “There were big gaps between those that provided robust services and those that provided the least. The whole promise of regionalization is greater consistency.”

This should mean more community facilities, such as the new Crisis Stabilization-Transitional Living Center in Ames. Mary Greeley is part of the Central Iowa Community Services mental health region, which includes 11 counties: Story, Boone, Greene, Marshall, Jasper, Hardin, Hamilton, Franklin, Poweshiek, Madison, and Warren.

“With the regional system, a patient shouldn’t need to be sent to Mary Greeley, and then Dubuque, and then Sioux City,” said Krause. “We should be able to work with resources within the region to help our high-acuity and general-care patients.”

Staff

Behavioral Health has more than 40 staff members, including nurses, social workers, therapists, and psychiatric assistants. The majority of the nursing staff are certified in psychiatric and mental health nursing.

“Our staff all want to work in behavioral health. They have a desire to be here and have pursued additional coursework and internships,” said Krause. “Some have a personal connection.”

Krause had a background in occupational therapy before transitioning to mental health care.

“In rehabilitation, your whole focus is on recovery and rehabbing the patient. Behavioral Health is no different,” she said. “We have to believe these patients can recover and go back to their lives, contributing to their communities and living independently. That is our goal.”

Nurse practitioners Lindley and Kapustka both opted for psychiatric nursing over typical medical inpatient care. The specialty provides Lindley opportunities to use her skills at one-on-one listening and forming connections with patients. It is continually challenging and satisfying work, she said.

“I remember once I was working with someone with limited cognitive ability who had been damaged by 18 years in the foster system. After finishing, I was immediately waylaid by another patient; this one had a PhD. I had to quickly change how
I was communicating. Every patient is different and you have to learn how to manage that,” she said.

Kapustka studied criminal justice and psychology and had hopes of being a probation officer. She opted instead for nursing school and pursued psychiatric nursing. In addition to working for Mary Greeley, she has a private practice. This can be beneficial
for Mary Greeley patients who become clients outside of the hospital because they already have a familiarity and comfort level with her.

Strosahl became interested in psychiatric medicine during her rotations as a medical student. She realized “what an impact you can have in all aspects of a person’s life in dealing with mental health issues and directing them through the difficulties they have.”

“I’m doing a job I love and I wish there were more resources. Sometimes in an inpatient setting we are getting someone in a healthy place and once they are ready to leave, you ideally want them to have all the necessary resources, like a psychiatrist, a well-trained therapist, and assertive community treatment,” she said. “It can be discouraging because they came for help and have to wait two to three weeks before a program can take them. It’s tough, but you have to keep at it.”

Dr. Usha Chhatlani recently joined the Behavioral Health Unit. She will treat patients at the unit, as well as being medical director for the new Crisis Stabilization-Transitional Living Center in Ames.

“I had always been in primary care, but whether I was doing internal medicine, family medicine, cancer care, I was always seeing psychiatric issues come up,” she said. “I gravitated toward this kind of care because it is so needed.”

Mayfield brings personal experience to her job. She had a brother who spent most of his life in a state hospital for the developmentally disabled. Another brother committed suicide when he was 22.

“He had attempted suicide once and was hospitalized. The feeling was that he did it for attention. He was discharged without seeking behavioral health care because they didn’t think it was a serious attempt,” she remembered.

Mayfield had worked as an assistant in an adolescent behavioral health facility. After losing her brother, she started applying to nursing schools to be a psychiatric nurse.

“We need more people to stand up for these people,” she said. “I need to be an advocate for them. We treat so many people here. The homeless, drug addicts—you have to be able to look past that and see a person, a person who needs our help. I want to make sure our staff are in this for the right reason, that they want to be advocates too. I believe all my staff are there.”

Future

So what would happen if Mary Greeley did not have an inpatient Behavioral Health Unit?

“You’d have a lot more individuals lost in the system,” predicted Lisa Heddens, director of National Alliance on Mental Illness Central Iowa. “If someone is in a crisis situation and needs evaluation … I don’t know how many people would have the means or support to find it elsewhere.”

Mental health is a “huge gap in the healthcare system,” said Heddens. Because of this, Mary Greeley is looking to expand its inpatient unit within the next few years. This will provide more general unit beds and, more importantly, more high-acuity beds.

“We have four now and it simply is not enough. The unit is always full,” said Krause.

A lack of providers and facilities has made it more challenging to provide intensive psychiatric care. A longtime psychiatrist who was also medical director for Mary Greeley’s Behavioral Health Unit has retired. Mary Greeley is exploring how one or more of its psychiatrists can provide more out-patient care, including being a resource for McFarland physicians who may be treating patients who have mental health issues.

“There’s a need,” said Dieter. “We don’t shy away from taking on physical health issues, and we shouldn’t shy away from taking on mental health issues. We can help. We should help. Patients and families need and deserve our help.”