Of all the underlying conditions the pandemic has revealed, the state of Americans’ mental health has perhaps the most worrying longterm implications. We’re more anxious, stressed, isolated, depressed, and suicidal than at any point in recent history. The virus has only made things worse, and left us fewer ways to cope.
A recent study from the Centers for Disease Control and Prevention found that in late June, 40 percent of US adults reported struggling with mental health or substance abuse, with young adults, BIPOC, and essential workers disproportionately affected. In Ulster County alone, opioid overdoses in the first five months of the year nearly doubled compared to the same period last year. The number of overdose deaths tripled.
“This is a time when people need mental health services, psychiatric services, and drug and alcohol services more than ever,” says Matthew Shapiro, associate director of public affairs for the New York chapter of the National Alliance on Mental Illness. “We know that people are self-medicating and finding unhealthy ways to cope with the stress, the trauma, the grief, the anxiety being generated by COVID, the economy, the racial issues—people’s mental health is being pushed like never before.”
So why was the only mental health and detox/rehab inpatient hospital unit in Ulster County shut down indefinitely in April? And why do nurses, healthcare advocates, and local officials now fear it will never reopen?
Turns out we can blame that on the pandemic, too.
“We all just felt it was very suspicious.”
By late winter, it had become clear that the scale of the response to the virus would need to be massive. To ensure that hospitals had enough beds to treat the surge of COVID-19-infected patients, on March 23 Governor Andrew Cuomo issued an emergency executive order mandating all hospitals increase available bed capacity by at least 50 percent. Like almost every large hospital, the Westchester Medical Center Health Network, which has 10 hospitals on eight campuses throughout the Hudson Valley, utilized every option available to free up beds, including consolidating services and converting existing units for COVID-19 use.
In early April, the 60-bed behavioral health inpatient unit at WMCHealth’s HealthAlliance Hospital: Mary’s Avenue Campus, in Kingston, was shut down. That unit provided the only psychiatric, detox, and rehab inpatient hospital services in Ulster County; it also regularly treated patients from neighboring Delaware County, which doesn’t have an inpatient psychiatry unit. WMCHealth transferred those services to another hospital in its network: MidHudson Regional, in Poughkeepsie, where they were blended with that hospital’s behavioral health ward.
That means that, since April, anyone requiring inpatient psych care who would normally be treated in Kingston now has to travel or be transferred by ambulance to MidHudson Regional, which is 20 miles away and across the river, or further still to other WMCHealth hospitals in Valhalla or Port Jervis. (Most patients needing detox or rehab services have been treated at the Broadway campus of the HealthAlliance Hospital in Kingston, according to WMCHealth.)
It’s a situation playing out across the state: At least six psych or detox inpatient units have been closed because of COVID surge plans, none of which have fully reopened, leaving hundreds of thousands of people with less access to critical mental health and rehab services at a time of heightened need. These problems are exacerbated by a healthcare system that reform advocates say consistently undervalues mental health, and industrywide trends that have led to consolidation of hospital services.
“Without these beds and without community support, we know what’s going to happen to people who need mental health services,” Shapiro says. “They’ll end up in one of three places: On the street, in the corrections system, or in the emergency room.”
WMCHealth created a third mental health inpatient unit at MidHudson Regional to handle the additional patients from Ulster County—not to mention the nurses, 35 of whom transferred to Poughkeepsie as well. But that new unit has only 15 psychiatric beds, 25 fewer than what had been available at Mary’s Avenue.
The anticipated surge of COVID-19 patients never arrived in Ulster County, however, and the beds at Mary’s Avenue that were cleared have not been needed. Many stakeholders now fear that WMCHealth may never reopen the Kingston behavioral health unit because of financial incentives against doing so.
“No matter how you ask the administration [about reopening the unit], they would never say no, but they would never say yes,” says one nurse who was among those who transferred from Kingston to Poughkeepsie, and who spoke on the condition of anonymity because he feared talking to the press would cost him his job. “We’d say, ‘At such point when the hospital is no longer designated as an emergency surge facility, will we be moving back?’ ‘We can’t answer that question at this time.’ There was never ever any clear language. We all just felt it was very suspicious.”
That suspicion dates to at least December, when WMCHealth abruptly closed 2 South, the 19-bed progressive care mental health unit at Mary’s Avenue, for a full-scale renovation, according to multiple sources. (Behavioral health at the Mary’s Avenue hospital is spread among three units: 2 South; SMC, a 21-bed acute care mental health unit; and a 20-bed detox and rehab unit.) 2 South didn’t reopen to patients until March, at which point SMC was then closed for minor renovations.
While the hospital had approval from the New York State Office of Mental Health to make upgrades to the units, two nurses allege that there was never approval to close them. Not getting official approval meant that, on paper, the Mary’s Avenue hospital still had 40 mental health inpatient beds. But functionally, it was only using half of them from December until the COVID shutdown. Amie Ebert, a former nurse at the hospital, and other nurses think this was done to purposely keep the hospital’s census low, indicating that the unit was being underutilized and not showing a profit.
In a statement, WMCHealth disputed that 2 South was closed. “WMCHealth initiated a process to upgrade the unit, and this process resulted in temporary access restrictions to some areas.”
But according to Ebert, the nurses were told, “‘Don’t say we don’t have the beds—we do—but we can’t use them, we’re not admitting, we’re diverting the patients out.’ We would hear from nursing supervisors all the time: They call to find out our bed availability and I would have to lie and say we have none.”
Then the pandemic hit. “I think they had this up their sleeve the entire time,” says Ebert. “COVID was the perfect excuse to move forward with their already-laid plans.”
The Numbers Game
Cuts in public-sector mental health services and closures of specialty psychiatric hospitals over the last few decades have forced general hospitals to pick up the slack. According to data provided by the New York chapter of the National Alliance on Mental Illness (NAMI) and the New York State Nurses Association (NYSNA), general hospitals treated almost 60 percent of patients requiring inpatient psychiatric care in 2018. At the same time, an estimated 44 million American adults currently live with a mental illness, and most don’t seek treatment in a given year.
“The objective need locally is extremely clear,” says State Senator Jen Metzger, whose district encompasses the area west of the river that WMCHealth has at least temporarily abandoned. “The mental health impacts of this pandemic have been enormous, and we’re going to be feeling those impacts for some years to come.”
Last week, the state Assembly held a hearing examining the impacts of COVID-19 on mental health services. OMH Commissioner Anne Sullivan revealed that telehealth claims increased by 55 percent from March to April of this year—which doesn’t capture the full extent of the suffering, since many rural areas of upstate New York lack broadband internet.
“We need the state to get back engaged and make sure that we have broadband and access to this technology across our state,” said Assemblywoman Didi Barrett, whose district includes parts of Dutchess and Columbia counties.
In a for-profit healthcare system, supply-driven demand leads to high prices for specific services. Since most mental illnesses are chronic, and patients who are hospitalized for mental illness typically have a long duration of stay, psychiatric treatment can be incredibly costly for hospitals. In New York, payment reforms phased in a decade ago lowered reimbursement rates in an attempt to “right-size” inpatient hospital capacity in the state. The average length of hospital stay declined, and more treatment was shifted to outpatient care. That shrank the net patient revenue per psychiatric bed from $99,000 in 2000 to $88,0000 by 2018, adjusted for inflation. Over that same time period, inpatient psychiatric capacity has declined by at least 12 percent statewide. A 2016 study from the Treatment Advocacy Center found that New York State had just 52 percent of the inpatient beds needed to treat severe mental illness in all populations, including the incarcerated.
It’s a numbers game, the terms increasingly dictated by private insurance, regional groups of private hospitals, and other commercial interests. What’s more, lack of access disproportionately affects poor and low-income people. Untangling the causal relationship between mental illness and poverty is complicated, but some studies have shown a correlation between lower levels of income and higher likelihood of mental disorders, and Medicaid is the single largest payer for mental health services in the US.
Hospitals face even more severe budget crunches in the wake of the pandemic and with elective surgeries—a major revenue generator—paused for nearly three months at the height of the crisis. Thus the fear that inpatient units will be on the chopping block, just when their services are most needed.
“One of the biggest problems is not having enough psychiatric coverage,” says Ellen Pendegar, chief executive officer of the Mental Health Association in Ulster County, a mental health advocacy nonprofit. “If you consolidate, who is going to suffer when the services aren’t in Ulster County? It’s going to be people with a lack of resources.”
WMCHealth, however, argues that it can still meet patient needs through consolidating units in fewer locations and shifting resources to outpatient care. In June, a revealing conversation between a WMCHealth executive and the host of a healthcare-oriented local public radio show illuminated the hospital network’s apparent doublespeak. Dr. Michael Doyle, the executive director and chief medical officer of HealthAlliance of the Hudson Valley, was a guest on “HealthCetera in the Catskills,” a WIOX show hosted by health policy expert Dr. Diana Mason.
“I have a question for you,” Mason begins. “Does the inpatient mental health unit and the inpatient detox unit—what’s the bottom line financially on those? Do they lose money? Do they make money for the health system?”
“That’s hard to say, and not something I want to discuss right now,” Doyle replies. “I think it varies.”
Mason: “I think there are some people in the community who are questioning whether this is being done because these are services that do not make money for the hospital. Because otherwise, during these times when revenues have dropped because of elective procedures not being allowed, if they did make money, wouldn’t that be one way to help the bottom line of the hospital?”
Doyle prevaricates in response. “What we’re more focused on with this, at least for the time being, as revenues through outpatient services and the decrease in volume—this is something we had to do, we had to close, we had to move those patients—that there is an opportunity to enhance the quality of service through consolidation. Instead of staffing two programs, we’ve moved the staff and all the jobs to one…there’s some reductions in costs, so we can get through that to help the system overall, but it enhances the quality of the programs through consolidation.”
I put that idea—that consolidation could enhance outcomes—to Senator Metzger. “I would say that taking services out of communities in need can never result in an improvement of care,” she says. In May, she wrote a letter to Doyle urging the HealthAlliance to return behavioral health services to the Mary’s Avenue campus “at the earliest possible time to do so safely.” Metzger has also been working with Ulster County Executive Pat Ryan to prevent the possibility of the beds not returning.
Nor has WMCHealth’s argument convinced others. Since the early days of the closure, a coalition of nurses represented by the New York State Nurses Association has mounted a public relations campaign to “Save Our Inpatient Mental Health Care & Detox at HealthAlliance,” peppering Ulster County with yard signs and bringing attention to the issues in a public Facebook group. And in June, the Ulster County Legislature adopted a bipartisan resolution asking WMCHealth to return inpatient mental health services to the HealthAlliance Hospital.
In order to permanently take a bed offline, a hospital must go through a Prior Approval Request process. As of early August, no hospital system had submitted a PAR application for closure, according to OMH Director of Public Information James Plastiras. “We expect that all of the beds will eventually be reconverted back to psychiatric beds,” he says. “Hospitals are exercising an abundance of caution to ensure they have adequate capacity to handle a potential second wave of COVID-19 in the fall.”
The New York State Department of Health issued updated guidance in mid-June that did away with previously established requirements for bed availability, while encouraging hospitals to continue monitoring their bed capacity, among other metrics, so they can make adjustments in the event of a COVID-19 resurgence. A spokesperson for the Department of Health says that “the department is in discussions with the Office of Mental Health and Westchester Medical Center/HealthAlliance regarding requirements for inpatient psychiatric services for the residents of Ulster and Dutchess County.”
WMCHealth declined to answer a specific question about whether it holds the position that the quality of service could be enhanced through consolidation, instead noting that there has been a 26-percent year-over-year reduction in demand for inpatient behavioral health beds, and that the hospital “continues to work with New York State’s Department of Health, Office of Mental Health, and Office of Addiction Services and Supports to restore the 25 beds within the network, as well as an overall plan for behavioral health services, based on expected returning volume.”
“It was like they were tired of us.”
To determine whether or not WMCHealth can provide adequate mental health care, it’s worth looking at the inpatient unit at MidHudson Regional. For this article, I spoke with more than a half-dozen nurses, assistive personnel, and former patients at the hospitals psychiatric inpatient unit, who all told a remarkably consistent story of a facility with few therapeutic activities, problems with cleanliness and COVID-19 protections, infighting among nurses, and friction between hospital staff and patients.
One of those patients is Kelsey Houskeeper, who was admitted to MidHudson Regional early on the morning of June 9. Intake begins in the ground-floor emergency room, where Houskeeper says she was given four benzodiazepines to help with her anxiety. The psychoactive drugs knocked her out; she doesn’t remember being transferred upstairs to 4 Spellman, one of three inpatient psych units at the sprawling hospital campus.
At 18 years old, Houskeeper barely cleared the age threshold for the adult ward; she was the youngest person there during her two-week stay. Mental health professionals generally agree that providing activities and other behavioral outlets is an important component of acute therapeutic mental health care, but at MidHudson Regional, Houskeeper and other patients say there is very little to do.
A vegan, Houskeeper says she lost six pounds in part because the hospital didn’t have meal options for her, despite telling her otherwise before she was admitted. Houskeeper says that the bathrooms on her floor frequently lacked paper towels, toilet paper, and soap, and that hospital staff rarely interacted with patients in a positive way. “We all agreed that unless someone has an outburst, they weren’t gonna get any attention,” she says. “It was like they were tired of us.”
One incident stands out for Houskeeper. After a few days on the unit, a man in his sixties began passing her love notes and staring at her throughout the day, even while she was in bed. Houskeeper gave the letters to a doctor, who shared them with a social worker, but no action was taken to separate the two patients. When Houskeeper mentioned the pattern of behavior to a nurse, the nurse suggested she put on a bra.
Asked if her stay at MidHudson Regional helped with her depression, Houskeeper laughs. “No,” she says. “I took something to go to sleep every night, I woke up to screaming, I went to sleep to screaming.
“It was definitely traumatic.”
The net reduction of inpatient beds, meanwhile, may have put Michael Baker, a 24-year-old who stayed at MidHudson Regional for one week in June, in an uncomfortable position. (His name has been changed to protect his privacy.) Baker was admitted to the psychiatric ward at 5 Spellman after expressing suicidal thoughts, where he was put in a room with another patient, Andre. One night, Andre had uncontrollable diarrhea, and draped his soiled clothes over a vent in the room. The following morning, nurses told Baker that Andre needed a room of his own, but that there was not one available.
It wasn’t the most disturbing thing Baker witnessed. On a separate morning, a patient appeared to experience a psychotic episode, alternately crying and making threatening statements. In response, a nurse named Matt confronted the patient, allegedly saying “I will fuck you up and knock your ass out.” Matt got in the patient’s face and hustled him into a room, where there were no cameras, before other nurses rushed to intervene.
Baker took notes during his stay at MidHudson Regional, and he reiterated the incident in an interview with The River. When the patient told a different nurse that he needed to talk to someone, Baker says that nurse replied: “No, you need to relax. You’re fine.”
Like Houskeeper, Baker says he was given strong sleeping medications that caused him to sleep through wakeup calls and miss group meetings, and that the bathroom on his floor often lacked soap or hand sanitizer. Baker says he was also not given a COVID-19 test despite having a fever of 99.9, and that hospital staff did not always wear masks on the unit.
In a statement to The River, WMCHealth says that hospitals in its network test “all behavioral health patients for COVID-19 prior to admission.” But in a July 27 letter the hospital sent to Baker in response to his complaints, WMCHealth Grievance Committee Chair Latisha Balogh-Robinson wrote that “all patients are screened according to CDC guidelines and, in accordance with the guidelines, if an infectious process is suspected, the patient is isolated from the general population.” The letter did not address Baker’s concern about not being tested.
Tension Between Nurses and Patients, and Among Nurses Themselves
I spoke with four frontline healthcare personnel who transferred from Mary’s Avenue to MidHudson Regional. All were alarmed by the standard of care at the Poughkeepsie hospital. After the Kingston unit was closed, its staff spent several weeks blended in with MidHudson Regional staff while the hospital quickly retrofitted a wing for the additional psychiatric unit. Multiple nurses describe that integration period as challenging because of differing policies and procedures, ranging from minor inconveniences like not being provided keys and having to learn a new system for logging reports, to larger issues around therapeutic strategy, including what was described as a “hands-off approach” with patients.
Amie Ebert, a nurse who worked at the Mary’s Avenue behavioral health unit for 17 years, was shocked by what she saw after transferring to MidHudson Regional.
“The conversation between staff members and patients can be quite confrontational at times and provoking from what I noticed,” she says. “There was just a complete disconnect between the staff and the patients. It was, ‘We’re here to keep you safe and here’s your meds,’ instead of working through whatever is going on with them and making sure they get something out of their hospitalization.”
The Office of Mental Health has a training program called Preventing and Managing Crisis Situations (PMCS), which is designed to provide inpatient staff with skills and methods to handle potentially dangerous situations—and to prevent them with effective day-to-day interactions. “At its simplest, it’s the rules of engagement,” explains the nurse who requested anonymity. “It’s about recognizing that all the patients in the hospital are there with some trauma…and focusing from the get-go on realizing this person is there for help, whether they know it yet or not.”
The nurse says that in the PMCS model, it’s important to make the patient feel like the staff is on their side, partners in helping them navigate their stay. “It’s highly important to make people think that they can get the towels and the body wash they need, some extra food if they’re hungry and an extra blanket without having to worry about somebody yelling at them,” the nurse says.
But when the Kingston staff arrived at MidHudson Regional, they were confronted with a very different culture. “We saw things that would’ve gotten people fired in a heartbeat,” the nurse says. He mentions witnessing a staffer hold a FaceTime conversation with earbuds in, looking at their telephone, with a patient sitting 10 feet away on their bed. “If something happened to that patient, this would be a clear case of negligence.”
The nurse said that hospital management was seldom on the unit, observing how things were going on a daily basis. “It’s much more hands-off here,” he says. “It seems to be much more of a knee-jerk style of management.”
That can have consequences on hospital operations that affect patient care. For example, the nurse says that on a number of occasions, supervisors made errors with scheduling, sometimes listing nurses who were off and not assigning the right number of nurses to each inpatient unit. When that happened, a nurse who had already started their rounds—checking on patients, logging reports, and meeting with the doctor on the floor—would then have to be transferred, and do it all again.
“You can’t help but feel like you’re abandoning the patients,” the nurse says.
Several nurses and patients described the unit at MidHudson Regional as cramped and crowded, with no outdoor access, poor ventilation in some rooms, and almost no common spaces, other than the hallway. An activities therapist who made the transfer from Kingston to Poughkeepsie says that MidHudson Regional had a “very skeletal activity therapeutic group program” in part because of lack of space, especially compared to what was offered at the Mary’s Avenue hospital. There, activities staff ran groups throughout the day, seven days per week, in a variety of configurations and therapies, including group therapy and dialectical behavioral therapy, recreational activities like therapeutic movement, arts and crafts, and skill-building exercises.
“We had higher quality services in Kingston,” says the activities therapist, who requested anonymity because she was not given permission to talk to the press. She also says that communication between different segments of the staff was not cohesive at the MidHudson Regional unit. “There was just such disorganization, a sense of not being safe.”
There was also tension between the existing staff at MidHudson Regional and the newcomers from Kingston. Because of chronic understaffing in the mental health sector, there are often opportunities for nurses to pick up overtime and set flexible schedules. But with a net reduction in beds as a result of the Kingston closure, when the two staffs were combined, some of those opportunities dried up.
“They did not want us there—they made that pretty clear,” Ebert says. “They thought that we were trying to steal their jobs, basically, and taking away from any overtime that would’ve been offered.”
The situation was made more complicated by the fact that the staff at MidHudson Regional are represented by 1199SEIU United Healthcare Workers East, while the HealthAlliance nurses are members of the New York State Nurses Association (NYSNA).
Emails between Janet Strominger, a NYSNA labor relations representative, and Alan Liebowitz, vice president of labor relations for WMCHealth, confirm what multiple Kingston nurses told me: That they were assured they would be governed by their existing collective bargaining agreement even after transferring to MidHudson Regional Hospital. In an email dated April 3, Liebowitz writes: “please be assured that the Hospital will abide by all terms and conditions of the current collective bargaining agreement between the New York State Nurses Association (NYSNA) and HealthAlliance Hospital, effective June 1, 2016 through December 1, 2022.”
But that wasn’t to be the case for long. In early July, all of the nurses were called into a meeting: 1199SEIU had filed a petition claiming that the continued presence of NYSNA-represented nurses at MidHudson Regional constituted an illegal erosion of their bargaining unit. To solve the problem, the HealthAlliance nurses’ positions would be furloughed, and they would simultaneously be offered the same jobs at MidHudson Regional as part of 1199SEIU.
The furlough letter sent to the HealthAlliance nurses was signed by Liebowitz. It also noted that the nurses may be reinstated in their old positions, “should any of all of the beds return to Kingston.”
Ebert initially transferred from Mary’s Avenue to MidHudson Regional, but she declined to reapply for her job as part of 1199SEIU (her position with the HeathAlliance remains furloughed). “To be quite honest, I did not feel safe working there,” she says. “It was not a very therapeutic working environment, and I really didn’t think it was the best fit for me compared to what I had been working with.”
What Is Lost?
Last October, WMCHealth broke ground on a $92.9-million, 127,000-square-foot expansion project at the HealthAlliance Hospital at Mary’s Avenue. When it’s completed sometime late next year, it will include a new emergency care center, intensive care unit, and family maternity center; enhanced surgical suites; remodeled centers for ambulatory surgery, infusion therapy, and endoscopy; new imaging, laboratory, and pharmacy facilities, and a new, welcoming lobby, according to the statement from WMCHeath provided to The River.
Not included in that list: inpatient mental health care.
“Redeveloping the Mary’s Avenue campus is the first component of a major, two-phase healthcare-advancement project that includes the consolidation of all hospital services to the Mary’s Avenue Campus and the conversion of the Broadway Campus into a walkable health village,” WMCHealth said in the statement.
With parts of the hospital closed during the pandemic, construction has accelerated. Some nurses and advocates fear that WMCHealth will use the ongoing construction as an excuse to keep the behavioral health unit closed even after the pandemic is over.
Rina Riba, the former president of NAMI Delaware County, has watched the desertification of mental health services up close. In 2009, A.O. Fox Memorial, a longstanding independent hospital in Oneonta, joined the Bassett Healthcare Network, which is based in Cooperstown. Within a few years of the merger, Fox had closed its crisis center and its adolescent psychiatry unit, which was the only one in the region, and the number of adult inpatient beds at Bassett had been halved.
The consequences are cascading. “It’s a hardship for patients, their families or other support people, and transport services to have to travel great distances for care,” she says. “Patients in crisis have the burden of long stays in emergency departments waiting for a bed, then long travel to their destination. Family members and supports are challenged with reduced opportunity to visit patients, and to meet with treatment and discharge planning teams due to work or other family responsibilities, sometimes with limited access to means of transportation. Hospital staff are challenged to find and make referrals in communities with which they are unfamiliar, for follow-up services for the patients they are discharging.”
And that process seems to be getting harder. NAMI and NYSNA conducted a joint survey this summer to gauge the accessibility of psychiatric services in the Hudson Valley. Seventy-eight percent of respondents said it was very difficult or somewhat difficult to locate and access inpatient psychiatric services in a non-psychiatric hospital, and more than half whose loved ones were transferred (or who themselves were transferred) because of shortages ended up in a bed more than an hour’s drive from where they live. Sixty-nine percent of respondents said they or their loved one was discharged too early.
In mid-August, Houskeeper checked in with me to see how this article was coming along. Two months after her initial stay at 4 Spellman, she’d had to return to MidHudson Regional after having a seizure, but now she was feeling better.
“I’m doing alright,” she wrote via text. “Fortunately it was only a 24-hour stay.”