A cure for the ‘catch-all’ emergency room

In Colorado, a new movement aims to provide an alternative for people experiencing mental health crises. But does it work?

 

Steven Ledwon woke with his arms strapped to a hospital bed. 

Police had picked up Ledwon, 55, in late April from a local shelter in Alamosa, Colorado, where he was hallucinating and speaking garbled Spanish. Likely triggered by a change in medication, Ledwon’s psychotic episode was compounded by crippling anxiety. Police dropped him off in the emergency room — a common destination for mental health patients, but one that may cause as much harm as good.

According to the Centers for Disease Control and Prevention, mental disorders like Ledwon’s caused 5.3 million visits to emergency departments nationwide in 2011, 4 percent of all trips. All too often, however, ERs are ill-equipped to handle patients whose illnesses are mental or emotional rather than physical. Not only are ER visits expensive — one industry analysis pegged the median cost at $1,200 — they take time and beds from patients who require physical care. The chaotic ER environment, too, is hardly conducive to mental health. During every hospital visit, Ledwon said, the needles, harsh lights and restraining straps made him feel even more anxious than when he walked in.

Despite the many drawbacks to ER visits, law enforcement often has nowhere else to house people who are clearly experiencing mental health crises but are not a danger to themselves or others. The emergency room, said Alamosa County Sheriff Robert Jackson, is “our catch-all.” Police here have few other options. The county jail is overcrowded, and just two officers in Alamosa have been trained in crisis intervention, which teaches officers to de-escalate situations involving people in mental health crisis. Alamosa, a town of 10,000 people that serves as a hub for those seeking social services throughout Colorado’s isolated San Luis Valley, has just nine beds in its ER.

Steven Ledwon relaxes in Mi Esperanza’s “comfort room” while listening to his favorite band, Pearl Jam. Ledwon, a recovering alcoholic who used to frequent the local emergency room, comes to what he calls the “Star Room” at the wellness center weekly, and says, “I wish I had this room at home. I would use it all the time.”
Rick Scibelli Jr./Solutions Journalism Network

Reducing unnecessary and counterproductive ER visits is one mission of Mi Esperanza, a small wellness center run by a behavioral health group in Alamosa. The goal is to give people in crisis everything they need, including breathing exercises to calm anxiety, talk therapy to handle tough emotions and case managers to help with life logistics.

Just as important is what you won’t find at Mi Esperanza: No needles, no harsh lights, no armed police officers. 

“The idea is you could come in here and no matter how you’re feeling, we have something for you … that will help soothe,” said Rick Esquibel, a certified addiction counselor who works at the center. 

You might walk right past the unremarkable concrete building that houses Mi Esperanza a few blocks off Alamosa’s main drag. Couches line the big living room inside. The name, “Mi Esperanza,” is Spanish for “my hope.”

In one therapy room, a waist-high pile of pillows fills an entire corner. The words “I want to be happy and safe” are scrawled in a child’s handwriting on a nearby chalkboard. A simple blue-ink drawing of a hot rod, made by a middle-aged man, lies on a table. Coloring helps even the toughest adults calm down and express their feelings, said Esquibel, the addiction counselor. Five mental health clinicians and two case managers staff the center. A former Marine works security, but wears civilian clothes.

The facility, which opened late in 2014, is attracting a growing clientele. This May, Mi Esperanza served 28 visitors — 20 more than it hosted in May 2015. Some stay for 30 minutes; others linger for hours. So far this year, the staff has referred three patients to the ER, deciding they needed regular medical care.

Mi Esperanza and other so-called “crisis living rooms” are part of an emerging movement to decrease the inappropriate use of ERs. In 2015, Colorado Springs’ mobile crisis response team brought 564 people experiencing mental health or substance abuse-related problems to that city’s crisis living room. In the past two years, similar facilities have opened in Denver, Boulder, Fort Collins, Pueblo and Grand Junction.

Some mental health crises could be better addressed by providing support and resources, exactly as crisis living rooms seek to do, said Barbara Harris, a DePaul University nursing professor who has studied living-room programs. In a recent study of one facility near Chicago, Harris spoke with a patient who equated hospitals’ heavy-handed treatment of mental health conditions to using a nuclear weapon to kill a small animal. Sometimes people don’t need emergency medical care; they just need to talk to a counselor.

Some ERs are creating special sections for people with mental health conditions, away from sights and sounds that might further upset them, Harris said. But living-room advocates want to keep those people out of the ER in the first place. 

Although crisis living rooms are catching on, they may not always be the right tool for the job. Some mental health crises, such as suicide attempts, require medical treatment, Harris said. And it’s hard to put a finger on how well facilities like Mi Esperanza are working. The number of people turning to Alamosa’s ER for mental health complaints has actually increased since Mi Esperanza opened, according to data from the San Luis Valley Regional Medical Center. In 2014, the ER handled 242 visits where patients complained of anxiety, suicidal thoughts, substance abuse withdrawal or other situational crises. In 2015, that number grew to 276.

Even Harris, the DePaul researcher, said data comparing the outcomes of living-room clients to those who received emergency medical care are lacking nationally. Instead, she and others point to anecdotal evidence. Most people in Harris’ study, for example, said they preferred the living-room environment to the ER when they were undergoing a mental health crisis. Many were repeat customers, returning to the living room when they felt stressed. For Harris, that’s a good sign.

One metric suggests Mi Esperanza may be helping, said Julie Ramstetter, who manages the Medical Center’s trauma program. Fewer chronic users — people visiting the ER two to three times per week — show up in Alamosa’s ER today than six months ago.

Yet Mi Esperanza’s hours may prevent it from reaching those who need its services most. Many people with mental health disorders end up in the ER in evenings or on weekends, Ramstetter said. Mi Esperanza is only open weekdays, from 8 a.m. to 5 p.m. When a man showed up to the ER with no physical injuries at 4:30 p.m. on a weekday earlier this year, Ramstetter thought he’d be a good fit for Mi Esperanza. You can wait here for two hours until a doctor can see you, she recalled telling him, or you can try this other facility. The man left. A few hours later, he was back in the ER.

Rick Esquibel, case manager for Mi Esperanza Wellness Center in Alamosa, Colorado. Also known as the crisis living room, the walk-in wellness center in Colorado’s San Luis Valley provides an alternative environment for people experiencing mental health crises.
Rick Scibelli Jr./Solutions Journalism Network

Steven Ledwon first visited the Living Room after the incident that landed him in the hospital earlier this year. A mental health worker brought him there after doctors decided he was stable enough on his medications and released him.

On a recent morning, Ledwon walked into a small, dark room, sparsely outfitted with one recliner and chair. Colored lights twinkled on the ceiling. Ledwon calls this the “Star Room,” where staff puts on calming music. For Ledwon, that means Pearl Jam or Pink Floyd.

“This is the most magical room for me,” said Ledwon, a former UPS worker with a weathered face and a gravelly voice. “It works miracles in here. You can go in there a train wreck, and five minutes later you’re breathing normal, thinking clear, and able to go home instead of a hospital.”

At first, Ledwon, a recovering alcoholic, visited Mi Esperanza every day — sometimes twice. He now lives in an apartment run by the San Luis Valley Behavioral Health Group, which also operates Mi Esperanza using operational funds and a state grant, and stops by about once a week. The staff bought him a cellphone and helps him see a doctor regularly. Ledwon hasn’t been back to the ER since.

Recently, Ledwon became agitated when he thought his prescription medications had not been filled properly. He knew the signs: tight chest, shallow breath, talking to himself. He headed straight for Mi Esperanza.

“People were shying away from me on the street, and I thought, ‘I better go in here before I get thrown in jail,’ ” Ledwon said.

He sat on a couch with Esquibel, who played a Pearl Jam song. Ledwon remembered a technique he learned at another recovery center long ago: When you’re thinking of something bad, try to focus on something good, like fishing. He closed his eyes.

Ten minutes later, Ledwon felt good enough to walk home.

This story is part of the "Small towns, big change" project through the Solutions Journalism Network.