LOCAL NEWS
3:00 am
Wed May 21, 2014

Cambridge Hospital To Integrate Psychiatric, Medical ERs

The two emergency rooms at Cambridge Hospital.
Credit Ibby Caputo / WGBH News

For the last four decades, Cambridge Hospital has had two emergency rooms: one for psychiatric patients, and one for medical ones. Soon, that tradition is coming to an end. Starting on June 4, all patients, whether they’re having an emergency of the body or mind, will be seen in the medical ER.

Emergency medicine doctor Ben Milligan, who is responsible for daily operations in the medical ER, said the medical ER already receives about half of the 5,000 emergency psychiatric patients that come to Cambridge Hospital each year.

"Essentially, it is a geographical change in which those patients will now be cared for down here with the rest of the patients we’ve already been caring for," he said.

Cambridge Health Alliance, which operates Cambridge Hospital, is billing this move as a merger. Milligan said they’ve found a way to preserve the service and the quality of care, while improving patient flow and access through the medical emergency room. But some staff and family members of patients who use the four beds in the psychiatric ER are calling it a closure, and they’re outraged. Nineteen jobs will be eliminated — including the job of nurse Ellen Lyons Connors, who has worked in the psych ER for the last 15 years.

"Everyone in the psychiatric emergency room, excluding the doctors, has been fired," Connors said. "Several weeks ago we were notified, but the hospital continues to profess this is a merger. There will be no more expert psych nurses caring for patients. There will be medical nurses that are very good at what they do, but they are not experts at providing psyche care."

Clinicians also will no longer be in charge of watching patients who need constant surveillance because they’re at risk of harming themselves or others. In the medical ER, security officers will take on that duty. And while the medical ER will have two dedicated psych beds, they won’t have video monitors, like they do in the psych ER. Also, those dedicated psych beds will be located next to the ambulance bay, a busy corridor where paramedics bring patients in on stretchers.

Psychiatrist George Cramer said he is so concerned about patient and staff safety that he has resigned.

"There is a complete change in the treatment philosophy model," Cramer said. "This is going to be a consult model. This means that the doc in the ER is going to have complete authority over the case. The psych people will be there as consultants. So that makes it very different."

This is not the first time Cambridge Health Alliance has tried to restructure psychiatric services, which make up a huge chunk of its business. A year ago there was public outcry over the hospital’s plan to close its child psychiatric inpatient unit. The plan was thwarted when the Department of Public Health declared the unit an essential service.

But Cambridge Hospital is losing money. A state report says it’s one of only 11 unprofitable hospitals in Massachusetts. The ER merger is expected to save about $1 million annually, but this fiscal year the hospital already is more than $21 million in the red.

Cambridge Health Alliance Chief of Psychiatry Jay Burke said it comes down to the fact the psyche ER is not affordable.

"The problem is with reimbursement from mental health services these days — it’s very difficult to cover our costs in maintaining that service," Burke said.

Covering psychiatric costs is a problem many hospitals in Massachusetts and the country face, because insurance reimbursement rates are so low they often do not cover the cost of care. Marylou Sudders, the former commissioner of mental health for the Commonwealth of Massachusetts, said that unlike in businesses where more customers means more profit, in the healthcare world, having more psyche patients can actually cut into the bottom line.

"All volume means is that you are loosing more money," Sudders said.

Sudders said she does not blame Cambridge Health Alliance for trying to improve its finances. It does serve more low-income patients than any hospital in the state, and more than half of its psychiatric and substance abuse patients are on Medicaid, which has low reimbursement rates. But Sudders is concerned that mental health is always the first thing on the chopping block because of poor reimbursements.

"There are other parts of healthcare that are very well reimbursed and very well financed," Sudders said. "You see hospitals adding things like surgical practices and orthopedics and the like. You rarely hear of hospitals increasing their behavioral health profile because it is — and I don’t mean this disrespectfully — but it’s a bottom feeder. It loses money for hospitals. It loses money in practices."

Sudders said we do not value mental health care as a society. But at a recent Cambridge City Council meeting, it was clear some people do value mental health services.

During public comments, Cambridge resident Janann Licklider told city councilors that Cambridge Hospital’s psych ER is her safe place, because it is her son’s safe place.

"We’ve used the psych emergency services 30 times, and we’ve never had a bad experience," she said. "I can’t say that about anything else in my life."

Licklider said she believes in the psych ER at Cambridge Hospital so much that she and her husband bought a condo a block away from it. That way, her son who suffers from Asperger’s syndrome and bipolar disorder, can walk there when he needs to.

"I asked him if he thought this was a good idea, to merge, and he said no, this is not a good idea at all," she said. "He’s been to the medical ER too, but he says psyche patients need it to be quiet. We need to decrease stimulation. And he just didn’t think it made sense."

It may not make sense to those who use the service, but hospital officials say it does make sense financially. Still, Chief of Psychiatry Jay Burke said it was not his preference to close the unit.

"What we had has been very special. It’s been very important. But we simply have to face the fact that circumstances have changed and we don’t have the money to sustain it," Burke said.

Burke said he is determined to prove that integrating the emergency rooms and streamlining care can work just as well, if not better for patients. And, he said, it is the industry standard.

But Marylou Sudders said the industry standard is not what Cambridge Health Alliance should be moving towards. 

"They used to be the gold standard," Sudders said. But now, she said, they are "run of the mill."