 Lakeland Public Television presents Currents with host Ray Gildow, sponsored by Niswa Tax Service, offering tax preparation for individuals and businesses across from the City Hall in Niswa and on the web at niswatax.com. Hello again everyone and welcome to Lakeland Currents. We live in an absolutely amazing period of time. If you think about it, the number one taxi company in the world does not own a taxi. Uber. The number one hotelor in the world doesn't own a single hotel room, Airbnb. They don't have one single room that they own. And yet when we deal with the issue we're talking about tonight, mental health, in many ways we still live in the Stone Age. And so our guests this evening are here to talk about mental health issues, specifically in maybe Crowing County, but this is something that can carry across a very, very wide range. I'm happy to introduce Adam Reese, a guitar exceptional player, who's the President of Ascension Health Central, which is the central region of Ascension Health, and we'll come back in a minute and talk about that. And Dr. Peter Henry, who is the Chief Medical Officer for this Ascension Health Central, but also for the broader Ascension Health, as I understand. Welcome to the program gentlemen. And maybe we could just give a little background about what Ascension Health is. I remember this used to be the St. Joseph Hospital and now it's a member of a much broader organization. Maybe one of you could talk about it. Sure. So the headquarters for Ascension, it's in Duluth and that was a merger of St. Mary's Hospital in the Duluth Clinic and that continued to grow. Their presence not only completely surrounds that upper eastern part of the state, but actually goes into western Wisconsin as well. And then as you sweep across you in the central area, St. Joe's Hospital, we have small clinics as far south as Pierce, for instance, as far east as Emily, as far north as Hackensack, and west in Pillager as well, and then there's some others in between. And then you just keep marching across and then our next sort of hub is in the Fargo area and they have a series of clinics and smaller hospitals as well surrounding them. So it's a large area, thousands of employees. What makes Ascension unique is that it is primarily a rural delivery system. Most of these large integrated systems are metropolitan based. And for those of us who are passionate about rural health, we've really enjoyed the Ascension system. I would just add that we have roughly 15 hospitals and about 64 clinics in our organization. So we do have a very large geographic area that we provide care to people. And roughly how many employees would you say are involved in the idea? It's around 13,000 between 13,000 and 14,000. Wow, that's impressive. Well I was at the meeting when your hospital gave the presentation on mental health in Crow Wing County and actually I was floored by the information presented there. And in a way I probably shouldn't have been because I grew up in Brainerd. And I remember when we had a large state hospital here where we dealt with the severe cases of mental illness. And I've been in places like Washington D.C. where I see people living in cardboard boxes. And we had this era we went through nationally where we started closing these hospitals and putting mentally ill people, and again I'm talking probably more of the severe cases out in the street so to speak. Well we really have done that literally and so when you came and said that one in four Crow Wing County folks were affected by mental health issues that was amazing to me. So maybe you could start with that. Yeah so we do regularly surveys and they're part of our community health needs assessment. And the survey you're referencing was quite extensive. We partnered with Crow Wing County Public Health and we have about 62,500 people in Crow Wing County and I can't remember the exact sample size but it was significant. It was in the six, seven hundred people range and it was again simply they were disclosing they were answering what kind of issues and concerns they have and they disclose that again this one in four number is struggling with some kind of mental health condition. Now that can be severe, it could be sort of psychosis at one end. It could be technically more less severe, more minor, however for that individual for instance if it's acute anxiety that can have a profound impact on one's work situation or at the home life as well. And everything in between. We know there's very high prevalence of depression in Crow Wing County. What's interesting is that there's been state surveys and I'm pretty sure the state average is about one in five. So this one in four, one in five, you can see we're not that much different. That's still very significant to me. It's different and it's significant as you point out Ray but what I find fascinating is that we never talk about it. You know it's interesting it's self-reported in our survey that we did within the Crow Wing County and the surrounding service area that we have that the self-report at about one in four instance but even go back to when I was in medical school a number of years ago when I was in training it was clearly recognized at that time about 30% of the people that come into a family physician or a primary care office with a complaint whether it be a somatic or physical complaint are really there as a direct result of a mental health condition. So one out of three even. So this is not an unrecognized problem within the medical community but I think the public and the knowledge as to how this affects so many people within our society and anxiety is probably one of the key ones especially in our younger population as well. I know the last couple of years there's been a lot of debate at the legislative level with the governor specifically Moose Lake and some of those institutions and again we're not always just talking severe cases here we could be talking like you said anxiety and other things but there's been a reluctance I think from the national level and from the state level to fix this. It seems like we're just shoving these folks into your kinds of system a health care system that isn't really designed to handle the number. I know Adam you talked about having people in I think in your emergency rooms staying there for extended periods of time could you just talk a little bit about the impact that has? I can briefly talk about the emergency department. Pete's actually the emergency room physician. In that area you know I've been here in the Brainerd Lakes area going on 19 years at St. Joseph's Medical Center and I've worked in the emergency department throughout that time and I will tell you up until roughly two years ago we almost never had anybody who had to be boarded in our emergency department. We had facilities where we could place them on a relatively short time frame to get them the ongoing care. What kind of facilities would that be usually? Well you know in the past when I first got here we had the state facilities we had the Brainerd facility because it was very close so those facilities were readily available there was room and patient beds available that we could transfer them. As the number of beds for mental health inpatient care has declined dramatically over the last 10 to 12 years that ability to move people from our emergency department and acute care settings into longer term where they can get all the services that are necessary to treat their mental health issues has dramatically decreased. And up until two years ago I was director of the emergency department assuming my position as the chief medical officer we really never housed anybody in our emergency department and now it is essentially there's very few days that we don't have somebody that's on who's being boarded in our emergency department and we're attempting to provide the care that they need but it's not the right place to do that. And that's not isolated to our facility here. This is across all of our Ascension facilities and it's also not just a rural area this is a huge issue within the metropolitan area and emergency departments there as well. Many emergency departments for example our emergency department in Duluth at St. Mary's has modified its structure so it can house people so they have a separate piece of their emergency department that is dedicated to housing mental health patients that can't be placed in the appropriate long-term care facility. 24 bed emergency department of which I believe four to six is dedicated directly to the care of mental health issue patients. And at one time this is a level two trauma so it's the major regional trauma center. We had 10 beds occupied by mental health patients and so then you were down to 14 beds that were allowed to treat the other conditions. So maybe just you know in defense of legislators of the past we probably were at one time over bedded in psychiatric facilities and with the advent of these anti-psychotic medication and others and Pete could comment more on that the treatments improved drastically and we didn't quite need what we had in the past and so they're probably at one point where some appropriate reductions. The challenge though Ray is that the reductions just continued year after year, decade after decade and we're now in a situation where Minnesota which many believe is probably the best healthcare in the country or one of the best. When it comes to mental health services we have less locked inpatient beds than any other state in the whole country which is just shocking. And so the crisis that Dr. Henry is talking about is really profound and a quick fix isn't going to work and so you know I appreciate the steps that the bipartisan legislature made and there will be a modest increase for instance for these community behavioral health centers. One actually in Baxter, they were designed for 16 beds, they were sort of defunded down to about 10 beds and hopefully they'll be able to get back up to 16 beds but when you're talking about an extra six beds here, an extra six beds there it's a step in the right direction but it's still a drop in the bucket. The level of this crisis is huge. And it's impacting people in different ways but just to share with you, Pete's talking about the emergency department. We have these patients in our ICU as well occasionally but a real travesty is that many of these individuals end up in the prison system in our jails and they can't get the care they need and had perhaps they had better treatment, we could have kept them out of that system. And the cost actually to care for these patients in the emergency department or in our jails is far higher than actually in an inpatient setting like at Enoka or St. Peter and so we're in this odd situation where we don't have the right resources, we're using other resources that really weren't designed for these patients and in addition we're costing the state more money than it really needs to use for this population that's now being underserved if you will. So it's certainly near and dear to our heart and our colleagues' hearts. We care about these people and we desperately want to do a better job to serve them. I can only imagine that a medical doctor is not really trained to deal with many of these issues you're dealing with but you don't have a staff of psychologists or a whole, I know you had, I think it was a psychologist or psychiatrist that was at the presentation I was at and he was talking about his load and it's just incredible. So I can imagine that medical doctors having to deal with these issues when that's not really what their background is is also very very frustrating isn't it? Well I think that most physicians who are staff in emergency departments are trained to deal with the acute psychosis and psychotic episodes that require treatment in the emergency department and most of these patients as Adam alluded to many of them have additional medical conditions that need to be treated so they end up in our intensive care unit but usually that can be stabilized within a day or two and beyond that then they require their ongoing mental health care and that's where the issue is because there's a wide spectrum as to general anxiety, mild depression, severe depression, depression with suicide ideation and then you get into the all the psychotic issues and then the violently psychotic issues and so protecting the communities. For years we had facilities where people who required more intensive treatment who were really at risk of harming themselves or others could be housed and treated and as Adam stated the number of beds for that has gone down dramatically partly related to the fact that we have much better medications that can treat these conditions. There still is however a small subset of these patients that really can't be treated in a community-based behavioral setting, a group home or assisted living facility or something along that line. They really require intensive treatment in a locked facility and they are at risk of harming themselves, other patients and also staff and that's where really the major crisis I believe in my opinion is coming is that we don't have places to put those people. So they now stay in our jails because they are so violent. When they're in our jails they don't get ongoing treatment, they don't get their medications that they need to, they don't get all the behavioral and psychotherapy that's available in a assigned unit for that and it's the same thing in our emergency department. We do what we can on our borders because we have them seen daily by mental health professionals but the other many modalities that go into mental health treatment can't be administered in our emergency departments, they really need to be in these specialized facilities for that and you know we for years have a system that we have different levels of care provided in different areas. So we are not a tertiary or what's called a quaternary facility like some of the large metropolitan areas or the Duluth facility in St. Murray's. We have capacity to treat fairly sick patients but there is a limit to the amount that we can treat and the same thing applies to mental health. We can apply and treat a majority of mental health conditions here in our own mental health unit but certain subsets that are very violent, that are at risk to themselves, to the community and to their family members and to staff need to be housed in a facility that is designed for that. And we've really limited or most of those beds are not available and NOCA treatment center is one of them which currently does not have the capacity to take on these patients. So they sit in our emergency departments. So I think crisis is an appropriate term. Absolutely and we get into these odd situations. So we have the grace unit, that's our inpatient psychiatric facility, for the most part was designed for voluntary admissions and now we're seeing more involuntary patients and some of these violent individuals. Those individuals historically, we still try to do this, try to transfer them to for instance NOCA but with the lack of beds, we're not able to do that and so these individuals can spend I think what upwards of 40 days? On average they're in our facility for 30 days. And you're maybe even in the ER? In the ER, the length of stay that we've had here and are at St. Joseph's is the maximum I believe was 11 or 12 days. Well that's still a lot. That's a long time but in our Duluth facility we've had someone there almost a year. Wow. And housed in our emergency. And that's not at all what that was designed for. Not at all. No. So what ends up happening Ray is that these individuals are taking up this space that also could have been used for many local and regional patients and so what they're finding is they're then forced to be transferred to a facility in Duluth, the Twin Cities, maybe Rochester, you know some other part of the state and they're separated from their family and their loved ones and because of the acute bed shortage we find ourselves accepting patients from those same locations. So a person from southeastern Minnesota finds themselves up here and the person from up here is down in southeastern Minnesota and so it really is, we're just not serving people as well as they deserve to be served but that's kind of the reality that we're in. I was reading that in the future the fastest growing disease in the world is going to be depression so that would suggest that these issues are going to expand and not going to go away. What would your recommendations be to people who can make the decisions to help solve the problem? Well I think that there's a huge spectrum of mental health so depression, most mild depression, mild depression can be adequately treated in the home setting. I mean a person comes in and sees their mental health provider, their primary care physician, gets the appropriate medication, gets ongoing counseling. A lot of this on the front end if we do a good job of treating depression, anxiety and even some of the more significant psychiatric illnesses on the front end we can prevent the more serious illness but there is a limit to that. There are still going to be a number of patients that are severely psychotic that cannot be housed. So the answer is that it's going to cost money and I think my message to the legislators is that this is a crisis. It is a not an isolated issue related to Brainerd or our surrounding area. This is a statewide and national issue and that at some point in time we need to commit as a community to putting dollars into place to treat this. We're not going to get smaller. Our younger generation, the millennials, they've shown that anxiety is probably the number one mental health condition that they'll be facing in the future and currently and we need to start addressing that on the front end. Even if you just look at the dementia and the Alzheimer's issue with the baby boomers, that's a crisis waiting to happen as well. And many of these people with mental health conditions such as Alzheimer's end up in our facilities as well because they don't have adequate treatment facilities to get placed in there. And Adam you mentioned earlier that treating them on the back end is actually more expensive than it would be to have that treatment right up front. Right, so really I don't think there's one answer. I think as Pete is sharing with us we definitely need more investment on the back end. No question about it. On the front end though it turns out that not only can we do a better job of collaborating primary care doctors for instance with behavioral health specialists in the community, therapists, counselors, social workers. But we as a community can take some ownership for this as well. And there's been a fair amount of research that suggests that in many communities including ours mental illness has a lot of stigma and so we don't talk about it and not talking about it actually can make things a lot worse because that individual is really struggling and they're losing perhaps social support mechanisms. And so trying to make it okay to talk about these things, being a good friend, being a good family member, that alone is very powerful. We also have lots of other people in this community that want to help whether it's through our churches, all sorts of other organizations. And so we have a broad-based community health approach. We call crowing energized. It's a movement here that a number of agencies are collaborating on. It's co-chaired by Ascension Health and the Public Health Department at Crowing County. But we're trying to share with businesses and other organizations that we can do simple little things in our everyday life that will make us more resilient and will actually help us combat perhaps some more milder forms of depression, help us cope with anxiety and other kinds of significant life challenges that come along. And so I really think that all of us if we can work on destigmatizing it, being just good friends, good neighbors and considering some of these very simple tools that are being shared through crowing energized, and if I could do a little plug, crowing energized is non-profit, anyone can Google it and materials are on the web. So the point here is that it's going to take a community, isn't it, to solve this problem? Do you see a movement back to, for the more severe cases, to more facilities like we used to have, do you see a movement to, I'm not just saying go back and have the full Fergus Falls operation or the brainer operation, but there needs to be beds or places for the more severe person and they don't have a place to go now. If a note is full, do you see some investment in that kind of operation again? Well, my hope is that there will be investment in the operation because I believe treating on the front end and a lot of the things that we talk about that crowing energized is promoting will help, but there is a crisis now that's not going to be met by approaching it from that standpoint alone. We, in the next five to ten years, the ability to care for these patients that are severely mentally ill needs to be met and that will require some building of facilities. And if you look at whatever cost that is estimated to be, if it's $200 million, if you look at the dollars that are currently being spent in our emergency departments, our ICUs that will be a small amount of investment compared to what we're currently spending in the most expensive care places to treat these patients. And they're not getting, we at Ascension are doing everything that we can to treat them appropriately in our emergency departments, but you can't treat severely mentally ill patient in an emergency department the same way you can in a facility that's designed to have the full range of mental health services available to them. And the security is also a huge issue. We want to keep obviously the patient themselves safe. We want to keep the other patients in our emergency departments safe. We want to keep our staff safe as well and we're doing whatever we can to make sure that we have designed our facilities, have appropriate security in our buildings to make sure that happens as do a lot of other facilities across the state. I would say the average person like myself, driving down the road, had no idea this problem is as severe as you're explaining it is. I think you're doing a great public service by bringing this forward so we can all understand that we have an issue that we need to deal with. I think that's a wonderful job you're doing. A family that has a member who is having real health issues, is it still the best choice to start with the hospital? I think the best place is to start with their primary care physician. The fact that Adam, and taking away some of the stigma is a key issue. It's interesting if your doctor tells you that you have a thyroid condition and that your thyroid gland is not producing enough thyroid hormone, and they give you a substance that's going to make your thyroid function better. Nobody has any stigma associated with it. I have hypothyroidism and they say, well, that's fine, that's a medical treatment. If we look at many of the mental health issues, anxiety, depression, there is a true biochemical basis behind a lot of that, along with the psychosocial pieces that go into that. But when somebody talks about, I'm going to give you an antidepressant that will help arrange the chemicals within your brain to work better. There's a different stigma associated with that, as opposed to treating diabetes with insulin and the medications we use, thyroid disorders with thyroid supplementation that we use. And we've got to remove that away. And I think the best place to start is in the primary care physician's office. And Adam alluded to earlier about bringing mental health together with primary care, so that you have social services, psychologists, psychiatrists within the primary care clinics. That's really a key thing as well to help coordinate that care, because so often what I see, if I'm a family physician in my office, as I stated before, about 30% of that is related to an underlying mental health condition. Wow. We're out of time. Thank you for bringing this information to us. It's very, very valuable. And hopefully we can see some new things developing. We appreciate you bringing us here and asking us to talk about this. Thank you very much, Adam. Dr. Pete. Thank you, Ray. Thank you. You've been watching Lakeland Currents, where we're talking about what you're talking about. I'm Ray Gildow. So long. Until next time.