Hospitals in Oregon will no longer be able to release patients who come into the emergency room in mental health crisis without taking steps to prevent suicide and find treatment.
The new state law is another thread in the patchwork of care for the mentally ill, who often fail to get proper treatment even when their behavior escalates into an emergency.
The state requires hospitals that admit patients for mental health treatment to have a protocol at discharge to assess suicide risk, the capacity for self-care and the need for outpatient treatment, along with a transition plan and a timetable for follow-up appointments.
But hospitals that do not provide mental health treatment, like Columbia Memorial Hospital in Astoria and Providence Seaside Hospital in Seaside, were carved out in a compromise to get the mandate through the state Legislature in 2015.
Hospital administrators had argued that doctors and nurses were not equipped to counsel the mentally ill on top of the stressful, around-the-clock demands of an emergency room.
“Basically, we didn’t buy that,” said state Rep. Alissa Keny-Guyer, D-Portland, one of the chief sponsors of the new law. “That’s not an acceptable answer to say, ‘We can’t do it.’ You don’t send somebody home who had a heart attack and say, ‘Sorry, we don’t have any help for you.’”
The new law, signed by Gov. Kate Brown in early June, takes effect this fall. Erasing the distinction between how patients in crisis are counseled in emergency rooms, compared to when they are admitted to a hospital and discharged, comes as new research shows that emergency room interventions can significantly reduce suicide risk.
Hospitals will have to provide copies of emergency room release policies to the Oregon Health Authority. The Health Authority will compile the information in a report to the Legislature in January on the progress and potential barriers in carrying out the law.
Another new law signed by Brown this month requires public and private health insurers to cover behavioral health assessments and medically necessary treatment for people in mental health crisis, a mechanism to help finance care.
“These bills ensure that when Oregonians reach out for help in a behavioral health crisis, they can access a broad range of mental health professionals, emergency services and critical support systems,” Brown said in a statement Friday after a ceremonial signing in Salem with advocates for the mentally ill. “Now, Oregonians in their most vulnerable moments will have the tools they need to recover, without undue financial burden.”
Columbia Memorial and Providence Seaside work with Clatsop Behavioral Healthcare — Clatsop County’s mental health contractor — on crisis response to the mentally ill. A crisis respite center that opened last summer in Warrenton is also intended as an alternative to emergency rooms or, in more severe circumstances, the county jail. The hospitals are a partner in the crisis respite center.
“CMH has been following this practice already and we are glad to have the state make this the standard policy for everyone,” Trece Gurrad, the vice president of patient care services at Columbia Memorial, said of the emergency room protocol in an email.
Janiece Zauner, the chief operating officer and chief nursing officer at Providence Seaside, said in an email that “we are working on developing innovative, sustainable solutions that actively engage community resources to meet the needs developed in these policies. We are beginning the work in each ministry this summer, and hope to have community-based solutions identified later this fall, before the legislation takes effect.
“Caring for patients with behavioral health needs is a priority, and we will be working on how best to implement targeted strategies in support of people in need.”
Social workers, police officers and prosecutors who regularly encounter the mentally ill recognize the challenge for emergency room doctors and nurses. But some have observed that hospitals at times seem unprepared to handle people in a behavioral health crisis and unable to link patients to treatment.
Tragedies, like the suicide of Carrie Barnhart, who jumped from the Astoria Bridge in 2015 after several interactions with police, Clatsop Behavioral Healthcare and Columbia Memorial involving her schizophrenia and depression, have drawn attention to treatment gaps. Barnhart’s family has filed a $950,000 lawsuit against Clatsop Behavioral Healthcare and Columbia Memorial alleging negligence.
Another suicide — Susanna Gabay’s Vicodin overdose in 2010 — inspired state action. The 21-year-old University of Oregon student from Mosier, who struggled with depression, had a psychotic breakdown and was placed in a hospital psychiatric unit on suicide watch. She killed herself just before a counseling appointment a month after her discharge.
Her parents, Jerry and Susan Gabay, said the hospital did not disclose their daughter was on suicide watch and told them she may — or may not — have another psychotic episode, not enough information to alert them of suicide risk.
The 2015 law that set a protocol for hospitals when discharging mentally ill patients also clarified medical privacy to help avoid leaving loved ones in the dark. Patients are encouraged to authorize hospitals to disclose information to caregivers, such as prescribed medications and behavioral warning signs that demand immediate medical help.
Follow-up appointments must be scheduled within seven days after discharge, or hospitals must document why the seven-day goal is not possible.
The law was named the Susanna Blake Gabay Act.
Jerry Gabay, who now serves on the board of the National Alliance on Mental Illness-Oregon, said he and his wife learned that medical providers are reluctant to talk with families about mental health “in a way that would be shocking if you came in with a broken hip.”
New research released in April found that suicide risk among emergency room patients in mental health crisis is reduced if they receive suicide screening from an emergency room doctor, guidance on treatment options when they are released and follow-up phone calls. The study, led by Ivan Miller, a professor of psychiatry and human behavior at Brown University in Rhode Island, showed a 30 percent decline in suicide attempts over a 52-week follow-up period.
“It’s very important, particularly with people in a fragile mental state, and super important if they may be suicidal, to want to have done an adequate assessment of their mental health condition, which is not always done. And in my personal experience, with my daughter, it was not done, when I was there anyway,” Gabay said.
“So you need to have an adequate assessment of what is the problem here. And then don’t just release them and say, ‘Hey, good luck.’ Give them a little bit of a transition. Have some plan about what you’re going to do. Make an appointment for them to see somebody.”