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NJ Hospital Responds to Growing Psychiatric Needs of Geriatric Patients

Clara Maass fills new gero-psych unit just as Hagedorn closing is expected to increase demand

A New Jersey hospital has responded to growing psychiatric needs of geriatric patients by adding 22 beds at Clara Maass Medical Center, a new unit that was nearly filled before its official opening.

Area psychiatrists and long-term care facility directors began sending patients "just because they heard about us on the vine," said Joe Hicks, executive director of the Behavioral Health Network of Barnabas Health, parent of Clara Maass in Belleville. "The need is really significant."

Hicks and other health experts predict the need to continue increasing as the population ages. They are also closely watching the potential impact of the June 30 closure of the state's Hagedorn Psychiatric Hospital in Glen Gardner, Hunterdon County, which specializes in gero-psychiatry.

Hagedorn is no longer taking new patients as it transitions to closure. Hagedorn had 193 patients on November 1, according to Ellen Lovejoy, spokeswoman for the state Department of Human Services, and the current census of 126 is lower than anticipated, as a result of community services and placements.

"Individual clinical assessments of each Hagedorn patient continues to determine the most clinically appropriate discharge placement, whether it a family residence, nursing home, supportive housing, or another psychiatric hospital," she said.

For years, the state has been striving to reduce the population of its psychiatric hospitals, and if possible keep patients in their homes or community housing, with the support of community mental health agencies. The total census of the state's psychiatric hospitals was 1,767 at the end of 2011, down 406 from five years earlier.

"There are some gero-psychiatric programs around the state, but not nearly what is needed," Hicks said. Hospital psychiatric units provide short-term treatment for psychiatric patients, who after several days or weeks are discharged to their homes, families, or to supportive housing in the community for the mentally ill, or to long-term care in psychiatric hospitals or nursing homes.

The state has been planning the Hagedorn shutdown for several years, and patients will instead go to Greystone Psychiatric Hospital in Parsippany, Ancora Psychiatric Hospital in Hammonton, or Trenton Psychiatric Hospital.

Human Services "is confident that the current and developing capacity in the mental health system is aligned to support the Hagedorn closure," Lovejoy said. "It's important to note that 'danger to self or others' is the standard for in-patient psychiatric hospitalization. The division has made considerable investments to ensure that individuals can return home to family, whenever possible."

Meanwhile, Clara Maas is responding "to the immediate needs in the local community," said Mary A. Ditri, director, professional practice for the New Jersey Hospital Association, for "a therapeutic environment that specifically treats adults and older adults." There are about 1,500 licensed inpatient psychiatric beds in New Jersey and "individuals sometimes must wait for days before an open bed becomes available."

New Jersey has been funding an expansion of outpatient behavioral health services as the state pursues a long-term goal of moving back into the community those with mental illness who don't need to be in psychiatric hospitals. But Ditri said there are not yet sufficient outpatient behavioral health services throughout the state.

"So individuals who may have been able to manage their symptoms without inpatient care end up in hospital emergency departments when they experience a crisis," Ditri said. "We see it every day in the state's EDs. The situation is complicated by the dearth of services for substance abuse, detox and for individuals who are dealing with a combination of behavioral health issues."

In 2005, about 231,000 adults seeking mental health services were treated and released from hospital emergency departments. Ditri said that number is now close to a half a million with more than 110,000 over age 55.

Human Services has been meeting regularly with the hospital association regarding concerns over the use of hospital emergency departments by mental health clients, Lovejoy said. A variety of possible measures are being considered, including: development of Behavioral Health Homes, where patients have both their medical and mental health care coordinated by a clinical team. They are also looking at working with Health and Senior Services for a call for more psychiatric short-term care beds, further development of Tele psychiatry, and developing an ER intervention program called SBIRT (Screening, Brief Intervention, Referral to Treatment).

The new unit at Clara Maass will predominately serve gero-psych patients, and will take a few younger adults who fit into a gero-psych program, Hicks said. The unit "was not designed to respond to the closing of the Hagedorn," but to "respond to the gero-psych needs that are in the community and in the state as a whole, certainly in this northern area," Hicks said. The Barnabas system has a total of 250 psychiatric beds and operates gero-psych programs in Toms River and in Livingston, whose large gero-psych program is the model for Clara Maass. "We have a lot of experience in gero-psych," he said.

The current demand means "there is more pressure on all of the [acute care hospitals] to have a shorter length of stay and try to stabilize the patients and get them into whatever outpatient kind of program that you can get them into, whether it's community mental health agencies or an intensive outpatient program," Hicks said.

So far Barnabas "has not in any great measure felt the effect of the downsizing and ultimately the closing of Hagedorn," said Hicks, who has opposed its shutting. "That will probably change some time in the future because patients that had been sent to Hagedorn for prolonged care will not have that opportunity."

Dr. Lina Shihabuddin is the medical director of the new Clara Maass unit, and her clinical specialty is gero-psych. Dementia is a unique issue for the geriatric patient, who may also suffer from other psychiatric illnesses, such as schizophrenia, bi-polar disorder, and depression.

Because the Clara Maass unit specializes in gero-psych, "we can do behavioral interventions. We train the families in how to work with dementia patients. Ideally, we like to return patients to the community -- to their homes, their families," Shihabuddin said. But if a return to home and community is not feasible, the patient may be placed in long-term care. And Shihabuddin said some patients come to the hospital from nursing homes. In some cases "they are very agitated and (the nursing home staff) cannot handle them." Clara Maass provides acute care and "and then sends them back to their long-term facilities." Getting the medication right is one aspect of gero-psych "but there is also a very big behavioral component" involving issues like how to approach the patient, Shihabuddin said. "We train the caregivers. The families come in for family meetings and we talk about how to pick your battles so you're not fighting over everything. Sometimes it's OK for them to just eat ice cream."

Debra Wentz, chief executive of the New Jersey Association of Mental Health and Addiction Agencies, agreed that demand could grow for hospital units providing short-term, acute gero-psych care. The aging population is one factor, she said, and the closing of Hagedorn is another. And the state is proposing major changes in the Medicaid program that provides long-term care for the elderly, with the goal of keeping more seniors living in their homes and communities, rather than in nursing homes.

"That is going to put more [elderly] people into the population," Wentz said. Those with mental illness, given the right supports, may be able to reside in the community "but as time goes by, they would tend at some point to need additional support and possibly at least short-term care beds to accommodate acute episodes, if not being their entire living situation."

The state opened 253 "supportive housing" beds for in the community as an alternative to psychiatric hospitals placement, and 106 new community beds are pending, Lovejoy said. Over the past three years the Department of Health and Senior Services has provided a certificate of need for the development of 83 psychiatric short-term care beds, the sort of beds Clara Maass has opened.

"The number of geriatric patients is growing really exponentially and is likely to continue to grow with the aging of the baby boom generation," said Phil Lubitz, associate director of the National Alliance on Mental Illness New Jersey. "And of course one of the big drivers of the need is the closing of Hagedorn, which has been the primary gero-psychiatric hospital in the state."

Lubitz applauded the opening of the gero-psych unit at Clara Maass. "This is really important because there is a shortage of these very local units that can offer short-term care for gero-psych patients. Clara Maass has a very good reputation and it's welcome that they are developing this specialized area of psychiatric care."

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