Officials believe that the sudden surge in demand at Butler Hospital may be tied to the deterioration of out-of-hospital mental health services for children around the state, especially a dire shortage of child psychiatrists and outpatient services.

01:00 AM EDT on Monday, May 15, 2006

BY FELICE J. FREYER
Journal Medical Writer

The hospitals that care for mentally ill children in Rhode Island have been bursting at the seams since the beginning of the year, unable to accommodate all the youngsters who need psychiatric hospitalization.

As a result, children who are considered a danger to themselves or others often wait for days at general hospitals and emergency rooms -- kept safe and stable, but without the care they need.

This "boarding" of mentally ill children in general hospitals has always happened from time to time, but hospital officials say that in recent months it's become a daily occurrence. This year, for the first time, the expected seasonal peak in demand simply failed to end at Bradley Hospital, the children's psychiatric hospital in East Providence, and to a lesser degree at the children's unit of Butler Hospital in Providence.

"Our front door at Bradley is like air-traffic control," said Bradley President Daniel Wall. "Planes are in the queue to land."

But hospital officials say they don't know whether the overflow reflects an increase in sickness.

More likely, they say, the high demand results from the deterioration of out-of-hospital mental health services for children around the state, especially a dire shortage of child psychiatrists and outpatient services.

These shortages lead to logjams at the entrances and exits to the psychiatric hospitals. Sick children fail to get outpatient care early in their illness and end up in crisis, trying to get a hospital bed. But many of those beds are occupied by children who no longer need hospital-level care but can't leave because there is no safe place to send them.

Last month, the Department of Health held an informational hearing on Bradley's request for a variance from state regulations so it can exceed its licensed bed capacity of 60 beds for a year. It is the first time any hospital has requested a variance to expand bed capacity.

Hospitals are permitted to exceed licensed capacity for temporary situations, such as seasonal fluctuations. But Wall, the president, said that this year there were no valleys after the seasonal peaks: demand shot up in January and stayed high. Since mid-January, Bradley has exceeded its bed capacity almost every day, typically handling 61 to 66 inpatients.

Even as Bradley stretches its limits, more children are waiting at hospitals intended to treat physical ailments. Since October, 164 mentally ill children have "boarded" at Hasbro Children's Hospital, staying on average two or three days -- but sometimes as long as a week. On the worst day, in March, nine mentally ill youngsters were boarding on the sixth floor of Hasbro, occupying more than a third of the beds on that floor.

Typically, these youngsters have attempted or threatened suicide or are endangering siblings or parents, Dr. Gregory K. Fritz, Bradley's medical director, said in an interview. All are screened and identified as needing inpatient care by someone other than Bradley staff, such as people working for an insurance company or the state program that pays for their care.

"That's what it takes to get in any inpatient unit now," Fritz said. "These are not kids who are just having a bad day."

Bradley provides evaluation and one-on-one supervision for the children at Hasbro, but Fritz said it's not a good situation. "Most of the doctors and nurses [at Hasbro] have not had psychiatric training," he said. "The wards are not designed for psychiatric kids."

Bradley is asking the Department of Health for permission to have up to 66 inpatients on a continuing basis.

Butler Hospital, a psychiatric hospital that includes a 32-bed unit for children and adolescents, is not seeking a variance but is feeling similar pressures. "Almost on a daily basis we have more requests for service than we have beds with which to give that service," Dr. Charles E. Staunton, medical director of the child and adolescent unit at Butler, said in an interview.

Fritz and Staunton blamed the demand on a shortage of child psychiatrists, who can make more money in other states, and the limited availability of outpatient care.

Fritz said that although about 50 people hold licenses as child psychiatrists in Rhode Island, many are not working full time at treating children. Results from a recent survey, he said, show that Rhode Island has the equivalent of 30 full-time child psychiatrists.

Only a quarter of them work outside hospitals as private practitioners, and most private practitioners do not accept insurance and require patients' families to pay cash. Fritz said he believed only "two or three" child psychiatrists in private practice take insurance. The waiting time for a medication evaluation is three months, he said.

Outpatient care is also poorly reimbursed. Bradley does offer outpatient services, but not enough to meet the need.

"If we could double the number of outpatient clinicians, they would be full in about two weeks," Fritz said.

Staunton, of Butler, said that health insurers worry that increasing payments for outpatient care would open the floodgates to people wanting to see psychotherapists. But he's convinced that in the long run it would be cheaper to make outpatient care more readily available, because problems would be caught and dealt with earlier.

In his presentation to the Health Department last month, Wall emphasized that Bradley's request for a variance is temporary. The hospital has been working to develop programs that will relieve the demand, he said.

But Wall acknowledged in an interview that Bradley has been expanding its alternative programs for many years, and despite expectations, the demand for inpatient care continues unabated.

In 1988, 90 percent of Bradley patients were confined to the hospital. Now, on any given day 450 children are enrolled in Bradley programs; only 13 percent are inpatients. Only half the hospital's income is from inpatient care, he said. Bradley offers day programs, home-based treatment programs, partial hospital programs, residential programs, three schools and outpatient services.

Wall said that the state -- which pays for the care of 60 percent of the children treated at Bradley -- plans to hire an agency to screen every child on public assistance who enters the mental health system to make sure that alternatives are tried before hospitalization. Wall supports the push for alternatives to hospitalization, but he's skeptical of the state's plan, saying the new system would probably divert just a few children from the hospital. "I don't think it's the magic bullet that they think it is," Wall said.

The Health Department expects to make a decision this week.

Donald C. Williams, the department's associate director for health services regulation, said the decision must focus narrowly on whether holding the hospital to 60 beds would cause it unnecessary hardship or would be contrary to the public interest.

"I think they made a pretty compelling case," Williams said after last month's meeting. "It would be hard to deny it. . . . We don't want to see kids without appropriate treatment."

Meanwhile, Bradley is planning to rebuild the hospital without increasing licensed capacity. Plans call for a new building attached to the current one, with 60 beds, all in private rooms, but with enough space that the hospital could take up to 68 patients during temporary spikes in demand. The old building would be used for alternative programs, Wall said. The hospital expects to apply for state approval for the building project in January.

ffreyer@projo.com/ (401) 277-7397