Health

Iowa's mental health efforts have plenty to heal

One family's travails illustrate haphazard approaches to care

Out for dinner with, left to right, Simon Ertzinger's sister, Secily Petre; his grandfather, Jim Ertzinger; Simon; and his grandmother, Dianne Alison. (Courtesy Kristin Ertzinger)
Out for dinner with, left to right, Simon Ertzinger's sister, Secily Petre; his grandfather, Jim Ertzinger; Simon; and his grandmother, Dianne Alison. (Courtesy Kristin Ertzinger)
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A car crash that left her son with shattered hips, a broken foot, arm and jaw wounds and internal injuries requiring multiple surgeries was a telling point for Kristin Ertzinger.

Emergency personnel and hospital staff worked diligently to save her son’s life. But in the years leading up to that crash, and the aftermath, Ertzinger and her son experienced a different story with Iowa’s mental health system.

“There are no other illnesses where patient history is treated with such utter disregard,” she said of her son’s battle with depression, anxiety and suicide attempts.

Simon Ertzinger, now 19, continues to heal physically from the crash that almost took his life in February 2017, but the struggle to find appropriate mental health care is ongoing.

Most recently, his managed care organization denied the enhanced services recommended for his treatment, including one-on-one staffing. Instead, he spends his days in a holding pattern at a crisis stabilization center in Cedar Rapids.

Kristin Ertzinger said she had hoped his insurance carrier would realize that approving services, in the long run, would not only assist her son, but save money by helping to keep him out of crisis situations and hospitalizations. He has been hospitalized more than 20 times, in various sites across the state.

“Some days are OK, some days are excruciating,” she said.

Iowa ranked last for state psych beds

The Treatment Advocacy Center of Arlington, Vir., which pushes for stronger mental health treatment laws for patients, ranks Iowa at the bottom of all states in the availability of state psychiatric hospital beds.

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Iowa’s situation was exacerbated when then-Gov. Terry Branstad in 2015 closed two of the state’s four mental health institutes.

That left Iowa with just 64 state beds for a population of 3.1 million people, or two state beds per 100,000 residents, compared with the national average of 12, the Treatment Advocacy Center report showed.

While state Department of Human Services officials say Iowa has 730 public and private unit crisis beds, that number is only one part of the equation, said Peggy Huppert, executive director of the National Alliance on Mental Illness in Iowa.

“There are a number of concerns,” Huppert said. She cites a shortage of psychiatrists and child psychiatrists among the issues facing Iowa, particularly in rural areas, as well as a lack of prescribers, such as Advanced Registered Nurse Practitioners and Physician Assistants with certification in psychiatry, who are proficient in prescribing psychotropic drugs.

An estimated 135,000 Iowans live with serious, chronic mental illness, the mental health alliance reports.

“That’s a lot of people,” Huppert said. “When they need a bed, they need a bed.”

A “bed-finder” tool, used by court officials, hospital personnel and others, shows on any given day Iowa might have 60 to 70 open beds for psychiatric patients, she noted. “The problem is, we don’t have the right kind of beds.”

Beds are needed for patients with severe, complex issues, those who have co-occurring conditions, such as substance abuse with a psychiatric diagnosis or other factors, including intellectual disabilities. These patients are especially vulnerable, Huppert said, along with patients with a history of violence or aggression.

“And if you have all four,” she said, “God help you.”

Attempts to bring more relief

New state legislation offers some hope.

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Gov. Kim Reynolds on Thursday signed House File 2456 that addresses a wide range of mental health issues, including: establishing new crisis intervention centers, allowing mental health professionals to disclose information to law enforcement to prevent a serious threat to the patient or identifiable victims; providing secure transportation with staff who have mental health training; and establishing “assertive community treatment” teams and intensive residential service homes that accept court-ordered commitments and offer a “no reject, no eject” policy.

Some of the provisions include treatment of substance abuse, which often accompanies mental health conditions, and address law enforcement personnel, who frequently are thrust into situations involving mental health crises.

Diane Brecht, vice president of residential treatment services for AbbeHealth, has been following the legislation and hopes funding will accompany it.

AbbeHealth’s Penn Center began in Delaware County, in northeast Iowa, with 60 residential beds for patients with brain injuries, mental health illnesses and intellectual disabilities and the elderly.

It since has expanded to include community-based services for people with severe mental health illnesses, providing “habilitation services” houses in Manchester, Vinton and the Cedar Rapids and Marion area.

Staff provide supervision and support with developing skills such as cooking healthy meals and coping and stress management for adults with serious illnesses including major depressive disorder, bipolar disorder and schizophrenia.

“Drive past the house and you wouldn’t know there’s someone with a disability or someone with a mental illness living there,” Brecht said.

The concept is popular with waiting lists, and undoubtedly, more of the houses could easily be filled but for a workforce shortage, she said.

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“There’s a huge need for that service,” Brecht said. “The challenge is finding enough staff.”

One year ago, Penn Center formalized an affiliation with UnityPoint Health-St. Luke’s Hospital in Cedar Rapids to provide more continuity of care, she noted.

The hospital is among the largest providers of inpatient psychiatric beds in Iowa, with 24 for children or adolescents; 30 for adults and 18 for geriatric patients.

University of Iowa Hospitals and Clinics in Iowa City operates one unit of 15 child/adolescent inpatient psychiatric beds; two units of 22 beds each to provide 44 beds of general psychiatric care, and one unit of 14 beds that focuses on the geriatric population.

In addition, the hospital operates a 15-bed medicine-psychiatry unit, which treats patients with co-occurring physical, medical and psychiatric disorders.

The Broadlawns Medical Center Inpatient Behavioral Health Unit recently has undergone changes at its 44-bed facility in Des Moines.

A four-seasons sunroom, with plans to incorporate a healing garden to promote patients’ access to sunlight, nature and fresh air, are among the physical improvements. Treatment includes medication, health coaching and exercise, and if a patient suffering from major depression has no positive response, electroconvulsive therapy is a new option at Broadlawns, said Dr. Earl Kilgore, director of government relations.

All of the beds are for adults, but Broadlawns also has three adolescent psychiatrists on staff to help fill a need in central Iowa, Kilgore said.

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Move to shorter stays

At St. Luke’s, Carol Meade, director of behavioral health, said the rooms — including some that are double-occupancy — often are full, depending on the time of year. Summer, for example, is not as busy in the child/adolescent unit.

An average stay for adults might last six to seven days, with comparable numbers for both younger and older patients.

That’s because the units are not designed to be long-term. Rather, Meade said, the staff focuses on those in crises, such as suicidal patients and those who pose a danger to themselves or others.

“Our goal is to stabilize folks and get them back into the community,” she said.

The short-term stays are a change from a few decades ago, when a 30-day stay may have been standard, she added.

Patients now see a psychiatrist and nurse practitioners, as well as social workers and registered nurses, and join in group therapy, recreational therapy and have one-on-one time with an assigned nurse.

Some patients are committals from the judicial system, while others are voluntary. Restraints and seclusion rooms are “not used lightly,” Meade noted, and are very closely regulated.

“We go through a lot of training to assure they are used as safely and as infrequently as possible,” she said.

Like other mental health professionals, Meade sees hope in Iowa’s new legislation, including better services for patients with complex cases. Similarly, as other health care providers in Iowa have experienced challenges with the change to privatized Medicaid, the hospital, too, has faced issues with reimbursements and sees patients and families affected, she said.

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Feeling the impact

Insightful and musically gifted, Simon Ertzinger had friends, but oftentimes struggled as a youth to get to school because of his anxieties.

“I knew I had potential, but I had too much anxiety and too much self-doubt inside me that I couldn’t enjoy it,” he said. “Not once.”

Teachers often said he was capable of doing his school work but wouldn’t complete it unless it was perfect. He suffered from depression and began skipping school in seventh grade.

While Kristin Ertzinger, who works as a graphic designer in the Quad Cities, sought help from multiple mental health care providers early on for her son, he didn’t find it helpful.

“The issues Simon had were deeper than anyone realized at the time,” she said.

She spent years shuttling her son across the state when beds weren’t available close to home, searching for help in various hospitals and treatment centers, and often taking time off work to attend to Simon.

During that time, she found the lack of continuity of care not only disturbing, but completely detrimental to her son. Psychiatrists offered different diagnoses at different sites and with that, prescribed different medications, but with little to no time to monitor the effects.

Hospital personnel “pretty much start talking discharge the minute they arrive,” Ertzinger said. Staff often seem concerned only with the days leading up to the hospitalization, and are unaware of his previous suicide attempts, she added.

When patients like her son are shuttled all over the state, their records might be in 10 or 20 different hospitals, she noted.

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Ertzinger also has found residential care facilities for people with mental illness will not take a person if he or she is too sick — as in too suicidal — leaving the family scurrying.

“A lot of times, the only two options are bringing them home and living in terror, or putting their loved ones out on the street,” she said. “I know families who have done both.”

 

This story was produced by the Iowa Center for Public Affairs Journalism-IowaWatch.org, a nonprofit, news website that collaborates with Iowa news organizations to produce explanatory and investigative reporting.

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