Anthony Vigil was discharged from the hospital despite exhibiting the most critical signs on the widely used Scale for Suicidal Ideation: the suicidal gesture or attempt that he made by trying to cut his throat and the specific plan to kill himself at the pipeline bridge. Under state statute, if a mental health patient has just attempted suicide or is judged by a psychologist or psychiatrist to “present a likelihood of serious harm to himself or others,” he or she can be committed for evaluation without a court order.
Dr. Anjali Dasari, CSV’s medical director for Behavioral Health Services, says CSV follows admission criteria that is standard across the behavioral health care industry and among insurance companies. Though she expects someone who was brought to the ED after a suicide attempt would need to be admitted, she says it would depend on the specific circumstances.
“If someone had attempted suicide that very day, I would think they are in crisis and they need help and they need to come in,” Dasari says. “But it depends; the situation can vary from patient to patient, so I think, if I were to be the admitting psychiatrist, I would take a look at the whole picture and go from there.”
There are degrees of suicidal intent, according to Mark Boschelli, the clinical director at Presbyterian Medical Services Santa Fe Community Guidance Center. In behavioral health care parlance, these are referred to as levels of “lethality.”
“The majority of the time, there’s people who do have suicidal ideation on a regular basis and quite often they are not hospitalized because their acuteness doesn’t meet the threshold,” Boschelli says. “Sometimes people are just struggling, and I guess they’ve been conditioned to say it’s suicidal ideation, when in fact it’s just that they’re feeling sad.”
Boschelli says some patients have been “conditioned” by learning that people will listen to them more closely when they say, “I’m going to kill myself, I’m going to hurt myself.”
PMSCGC runs a program called the PACT (Program of Assertive Community Treatment) Team, which works specifically with the top 50 emergency room “frequent flyers” in an attempt to keep them out of the ED at CSV. The PACT Team receives some money from CSV as a treatment “scholarship” for patients not covered by Medicaid.
CSV Board Member and North Central Director of PMS Larry Martinez defends the ED’s process of screening potential IPU patients, saying that people who complain of their family member not being admitted are often mistaken about the appropriateness of inpatient care under the circumstances.
“The hospital winds up getting a disproportionately large number of people going to the emergency department when many of the reasons for their going is due to a behavioral health issue,” Martinez says. “Oftentimes the emergency department is not the appropriate place for someone who’s addressing a behavioral health issue. It’s where care is the most expensive, and the emergency room department can only go so far in responding to the behavioral health needs of the individuals.”
In the fall of 2009, CSV considered closing its IPU altogether. The Santa Fe chapter of NAMI derailed that plan by organizing public meetings and laying out the consequences of northern New Mexico being left without such a facility.
But after committing to keeping the unit open, CSV commissioned what it terms a “utilization study,” an as-yet-unreleased report created by health care consultant Howard Gershon. CSV has so far declined to release the report’s findings or the changes to CSV services that may be made as a result.
But according to NAMI Santa Fe member Martha Cooke, the “Gershon study” focuses on the amount of money IPU loses annually and what can be done about it. Cooke, along with other NAMI Santa Fe members, has been present at closed meetings with the hospital when the report has been discussed.
The study reportedly finds that the hospital takes a $1 million loss annually on the IPU, Martinez—who has also seen the study—tells SFR. Another topic is the issue of the ED “frequent fliers,” an issue brought up by CSV staff at Santa Fe County Indigent Hospital and Health Care Board meetings going back over a year. The partnership between CSV and the PACT Team appears to be an example of the direction CSV will be trying to move with its psychiatric care. If CSV offers funding to outside organizations that decrease dependence on the hospital’s resources for the most serious cases of mental illness and addiction, it can tighten its profit margins.
Judge Vigil says the prospect of changes to the IPU based on a utilization study worries him.
“I hope they’re not going to do even less…I think that’s just fancy talk for less services,” Judge Vigil says.