Nurses, patients, advocates speak out
by CHRIS ROGERS
Samantha Callahan is not afraid to talk to about it. It’s part of life. “I have struggled with multiple mental illnesses pretty much my entire life,” she explained. Most of the time, the young woman manages her mental health with support from her service dog, visits to her therapist, and check-ins at the psychiatrist’s office. But a few times, she needed more.
“I was hospitalized with suicidal ideations the first time when I was 20, maybe when I was 19,” Callahan said. “Since then, I was hospitalized two more times for the same thing.” In those moments, Callahan explained, it was not safe for her to be alone or even to stay with family. Spending a few days at the inpatient psychiatric unit at Winona Health protected her and allowed her to get back to normal. “It’s always been very helpful — just having a safe place to be where they would watch over me for as long as I needed,” she said.
“It has meant the world to me that there was a safe place for her to go in times of crisis,” Samantha’s father Ed Callahan said. “Sometimes I wonder if it has saved her life.”
Winona Health is closing that inpatient psychiatric unit. Also called the behavioral health unit, the hospital wing had eight beds and a staff that specialized in mental health care. Hospital administrators said they will still provide inpatient psychiatric care through the hospital’s general inpatient units, including the intensive care unit and medical-surgical unit. They stated that the kind of care and the quality of inpatient psychiatric care provided will not change. Nurses from the behavioral health unit, other Winona Health staff members, and patient advocates from the local National Alliance on Mental Illness (NAMI) chapter stated the closure will negatively affect the quality of care patients like Samantha receive and that more patients may be sent elsewhere for care, far from family, wherever beds are open.
The closure comes roughly a year after Winona Health chose to de-license its behavioral health unit. After that de-licensure, the unit was no longer able to accept 72-hour holds. Short-term involuntary placements for patients who are a risk to themselves or others, 72-hour holds are often the best tool for family members to make sure their loved ones get care in a mental health emergency.
Across the state, there is a shortage of inpatient psychiatric care. Currently, Winona Health’s behavioral health unit is not accepting new patients, but it has remained open while hospital staff have been trying — for the last few weeks, according to staff — to find a facility elsewhere that can take the unit’s last remaining patient.
“If somebody wants to say the behavioral health unit has closed, they can say that,” Winona Health CEO Rachelle Schultz said in an interview when asked if it would be fair to say the unit was closing. “We’re not using that unit; we’re not using those beds. We’re using these beds.” She added, “We don’t anticipate a change other than being in this room over here instead of that room over there.”
In a September 10 press release,
Winona Health leaders said they were integrating the psychiatric unit into the hospital’s general inpatient services. Psychiatric care would still be available, but as part of general medical treatment, not in a dedicated unit. The administrators said the reason for the change was to provide more holistic care to patients. “We are intentionally working to integrate behavioral health into our primary care and inpatient services to support a patient-centered holistic care approach,” Schultz stated. She added, “We’re taking care of people who have mental and behavioral health concerns throughout our organization, from outpatient psychiatric and counseling services to urgent care and emergency departments, to primary care clinics and inpatient care every single day, and we’ll continue to provide that care.”
“The care that we’re providing is not changing,” Winona Health Media Relations Coordinator Karen Sibenaller said.
The press release also stated, “No positions were eliminated with this care model transition and Winona Health continues to have career opportunities available.”
Back on September 5, Winona Health administrators handed a letter
to the behavioral health nurses and other employees from the unit that read, “Your position has been eliminated.” The hospital leaders broke the news that they were shutting down the unit and cutting their jobs at a meeting that day. They offered the employees other open positions in the hospital.
Asked about the press release’s claim that no positions were eliminated, Schultz said in an interview, “To clarify that, no people were eliminated. We didn’t tell anyone, ‘You can’t work here anymore.’”
Winona Health did eliminate nursing positions and other roles that specialized in psychiatric care.
Nurses: this change will affect care
Six Winona Health staff members, mostly nurses from the behavioral health unit, came forward to share their concerns about the closure. They spoke on condition of anonymity because they feared retaliation.
“Anyone who starts to ask questions realizes that this is an ultimate disservice to mental health patients at a time when we need more mental health units,” a Winona Health mental health professional said.
“Number one, you have nurses that aren’t psychiatric nurses,” a behavioral health nurse said. “Mental health is specialized,” the nurse continued. Just like she would not know what to do in a delivery room, ICU nurses do not have expertise in this kind of psychiatric care, another nurse said. “I don’t think those are people that are really qualified to take care of people they’re seeing,” the first nurse stated. The behavioral health staff explained they have specialized training in de-escalation, responding to negative side effects of mental health medication, and other skills to care for high-need mental health patients. Their patients are sometimes so depressed they’re catatonic; sometimes they act aggressively toward staff. The behavioral health nurses said they know what to do in those situations, and their patients have a safer, quieter environment in the behavioral health wing. They raised concerns that patients would be more likely to be put in physical restraints or confined to their room. “Those [ICU] nurses, they’re wonderful people, but they’re not psychiatric nurses,” the second nurse stated.
“We know what we’re doing,” Schultz said when asked whether psychiatric patients would be cared for by nurses and staff who specialize in mental health. All across the hospital, she explained, “We’re dealing with mental health issues all the time every day.” All of Winona Health’s departments care for patients with mental illness, Schultz stated. “So it’s not different for us to have someone with mental health concerns in our ICU or our [medical-surgical unit].”
The behavioral health unit’s eight rooms were devoid of ligature risks — any objects suicidal patients could use to harm themselves. A normal hospital room is full of them, one of the nurses said. In preparation for the closure of the behavioral health unit, Schultz said that Winona Health had removed ligature risks from some of the hospital’s rooms so the rooms could accommodate psychiatric patients. She did not know how many. The psychiatric nurses said they had seen that Winona Health removed ligature risks from three rooms. They raised concerns that the change would reduce the number of beds available to behavioral health patients.
Asked about ligature risks in the ICU, Schultz said, “Anyone who is in the ICU isn’t going to be up and out of bed.” As for the hospital’s capacity to treat behavioral heath patients, she said that there might be less access for patients from distant parts of Minnesota. However, she added, “We’re licensed as a 49-bed hospital. On any given day we have 20-30 patients … So we have capacity.”
Recreational therapists, counselors, chaplains, and other therapists would visit the psychiatric unit regularly to offer group sessions to the patients, behavioral health nurses stated. Those sessions gave the mental health patients a chance to see that they were suffering from a kind of disease that other people suffer from, too. “Peer support — That’s huge,” one nurse stated. It makes patients feel, “I’m not alone,” she explained.
The behavioral health staff members stated that because mental health patients would be spread out among other kinds of patients, those group sessions would no longer be possible. Schultz initially said it has been over a year since Winona Health has offered group therapy session in the behavioral health unit. Asked if the psychiatric nurses’ claims were incorrect, Schultz responded, “They probably have a lot more detail than I do. What I’m really responding to is, long-term stays where you’re doing intensive therapy and things like that — we’re an acute facility.” She explained that those kinds of therapies are more common at long-term treatment facilities, and she stated that has never been the focus at Winona Health.
Asked about Sibenaller’s statement that care would not change, a Winona Health mental health professional said, “That just can’t be when you go from an eight-bed unit with trained nurses to three beds on a medical unit without trained medical health staff or specific mental health programs.”
“It makes no sense that you can just integrate mental health into the rest of the hospital,” Ed Callahan said. “It is a speciality. It requires different physical characteristics of the treatment area. It requires different staffing.”
Why is this change being made?
Why did Winona Health make this change? “I think there’s a lot of different reasons,” Schultz said in a recent interview. She talked about the uptick in cases of mental illness that providers across the country have been experiencing. “I think over time as we’ve seen behavioral health and mental health become more pervasive in all areas — and again you step back and think, ‘We really need to think holistically about the whole individual.’” She added, “It’s very common in mental health for institutions to say, ‘How do we integrate primary care and behavioral health?’”
Schultz said there is a shortage of inpatient psychiatric care across the country. Asked why Winona Health chose to close its unit, Schultz responded that some larger institutions have more resources to deal with very high-acuity patients. “It’s hard to keep those kind of resources in a small community,” she stated, describing the difficulty of recruiting psychiatrists as an example. “It’s overwhelming lots of institutions and facilities, but I think smaller communities have a lot of difficulty. We have one psychiatrist. I can’t have one psychiatrist on call 24/7/365. That’s just not doable,” she stated.
So did Winona Health leaders feel that they did not have the resources to provide this kind of care? That wasn’t it, Schultz said. She explained that she and other leaders asked themselves, “Is there a reason why [behavioral health patients] need to be in a separate unit? And the answer was, ‘No, they don’t.’ … We could incorporate them and care for them in our other unit just as well as we could care for them in any other unit.”
Mental health care is not a money-maker for anyone, but Schultz said that financial concerns were not the reason for the change. “We’re still taking the patients, and we still don’t make money on them, so I don’t know what’s changing in that respect,” she stated. However, controlling the costs of health care is important and there is a potential upside to the change, she noted. “If we integrate our staffing and use them better, that helps us do better on the cost side,” Schultz explained.
Helen Newell, the president of the Winona branch of NAMI, said she believes the funding for mental health care is part of the reason for the shortage of psychiatric services across the state. She noted that the reimbursements government-run health insurance programs offer mental health providers is often just a fraction of what their services cost to provide. “That’s why those of us who are advocates need to keep hammering away at the legislators to make sure this is funded,” she stated. “It’s stupid, because dollar-wise it’s so much more affordable to have someone go into a [psychiatric] unit rather than an emergency room,” she added.
Other local agencies concerned more patients will be shipped out
The mother of a former patient said she called Winona Health to ask what the integration of the behavioral health unit would mean for her child. She said she was told that the press release explains everything. “No it doesn’t. No it doesn’t at all,” the mother stated.
Ed Callahan, too, said that after reading the press release, he was left wondering what would happen to his daughter the next time she needs to be hospitalized. “It scares me. It scares me that I don’t know where they can put here if she’s in crisis,” he said.
“We’re getting some mixed messages,” licensed professional clinical counselor Kateri Johnson said. Johnson works for Winona State University’s student counseling service and said that in a typical semester, her office would refer 2-4 students to Winona Health’s behavioral health unit because of suicide concerns. “From our understanding, they’re closing their doors … However, we heard they’re still serving people, that they have some beds in the ICU. However, I don’t know if that’s accurate.”
Johnson continued, “We were told that if [students] need more long-term care … it’d be likely that they’d be transferred elsewhere.”
Newell said she heard the same thing from mental health agencies and other organizations that refer clients to Winona Health: more patients would be sent to distant facilities far from family and friends.
Winona Health officials said the type of patients they would treat in Winona and the type of patients they would seek to send to other facilities would not change as a result of the behavioral health unit closing.
“That’s really scary for us — not knowing what’s going to happen with these students, especially if we have students from Illinois and all of a sudden they’re being transferred halfway across the state,” Johnson said. “That puts their family in a difficult position.”
Samantha Callahan said that if she or other patients had to be transferred to distant facilities for care, “It would mean I’d be far away where my family can’t be part of my support system. It really would deprive people in our community of their support system when they need it most.”
Convincing people to seek inpatient psychiatric care can be hard enough, and not being able to give students a clear idea of what to expect at Winona Health can make that harder, Johnson said. “I wish there was a little more clarity and transparency from Winona Health so they’re weren’t these mixed messages,” she added.
“I don’t know much more than was in the paper to be honest with you,” Hiawatha Valley Mental Health Center Executive Director Erik Sievers said in a late September interview. Sievers’ organizations offers a wide-variety of mental health services in Winona, from outpatient counseling to supportive housing. Hospitalization is not one of those services, but the organization’s clients occasionally need that level of care. “If someone is hearing voices and is difficult to manage and is somewhat suicidal, I don’t know if the plans are if there’s still a place for them at Winona Health or not,” he stated.
Schultz said that Winona Health will continue serving suicidal patients, but that the hospital always referred violent patients to other facilities.
“In working with physician leaders to evaluate the impact of this change, Winona Health anticipates limited change to patient access,” hospital leaders wrote in their press release. “Patients will continue to be assessed for safety and the appropriate level and location of care,” they added.
Care elsewhere in region
While experts say there is a shortage of beds, there are several inpatient psychiatric facilities in the region. In addition to Winona Health’s integrated behavioral health care offerings, the Mayo Clinic has a 16-bed inpatient psychiatric facility in Albert Lea, Minn., and offers care at other locations, as well. Gundersen Health System operates a 30-bed inpatient psychiatric facility in La Crosse. More facilities are available in the Twin Cities; Eau Claire, Wis.; Madison, Wis.; and elsewhere.
Southeast Minnesotans experiencing a mental health crisis in may contact the Crisis Response for Southeast Minnesota at 844-274-7472 at any time.
Share information about mental health care with reporter Chris Rogers at firstname.lastname@example.org