A Center for Health Information and Analysis report released October 13 details the impact of comorbidities among behavioral health patients on longer stays and unplanned readmissions
MNA nurses and healthcare professionals have long fought to protect mental healthcare services and improve staffing to reduce avoidable readmissions
CANTON, Mass. – A report released October 13 by the Center for Health Information and Analysis (CHIA) focusing on patients with comorbid behavioral health conditions and avoidable readmissions sheds light on structural problems in our healthcare system that the nurses and healthcare professionals of the Massachusetts Nurses Association (MNA) have been seeking to address since long before the COVID-19 pandemic.
“Patients deserve better from our healthcare system, especially patients who come to hospitals in desperate need, suffering from a combination of mental health, substance use or medical issues,” said Katie Murphy, a practicing ICU nurse and President of the MNA. “The hospital industry has long failed these patients by shuttering mental health services or operating with barely enough staff to keep the lights on.”
“The government must also take responsibility for not protecting essential healthcare services and not treating mental health equally despite the parity law,” Murphy said. “Hospital executives have made this crisis worse through their focus on profit margins over providing the level of care needed by patients with mental health challenges and comorbidities. Since the industry only responds to financial incentives, increased reimbursement for mental healthcare may be the carrot that convinces hospitals to help alleviate this crisis.”
The CHIA report is part of a statewide, all-payer examination dating back to 2016 of the prevalence of comorbid behavioral health conditions and readmissions among hospitalized adults in Massachusetts acute care hospitals. The latest report, entitled “Behavioral Health and Readmissions in Massachusetts Acute Care Hospitals SFY 2020,” is the first to include data from the pandemic, covering March to June 2020.
- Almost half (46%) of adults hospitalized in Massachusetts acute care hospitals had at least one comorbid behavioral health condition, representing a majority of discharges (54%) in SFY 2020. This pattern continued during the first wave of the COVID-19 pandemic (April-June 2020).
- Over sixty percent (62%) of hospitalized adult Medicaid patients had a comorbid behavioral health condition.
- Patients with any behavioral health comorbidity had inpatient stays that were, on average, 1.4 days longer than patients with no behavioral health comorbidity (6.0 days vs. 4.6 days).
- Readmission rates for patients with any behavioral health comorbidity were nearly double the readmission rates for patients without any comorbid behavioral health condition (20.6% vs. 10.6%).
Loss of Mental Health Beds in Massachusetts
MNA nurses and healthcare professionals have for many years fought to preserve mental health beds and services. The association’s efforts have included strongly advocating for laws that give the public more time and ability to provide feedback on healthcare closures, and that provide the state greater enforcement powers. The MNA is currently researching the impact of mental health boarding on patients, caregivers, and healthcare facilities in Massachusetts.
Closures or proposed closures of mental health services in Massachusetts:
- All (22) mental health beds at Baystate Franklin Medical Center in Greenfield.
- All (28) mental health beds at Baystate Wing Hospital in Palmer.
- All (20) mental health beds at Baystate Noble Hospital in Westfield.
- The three above proposed closures are part of an ongoing plan by Baystate Health to open a for-profit mental health facility in Holyoke.
- In 2020, Trinity Health closed 74 child and adult mental health beds at Providence Behavioral Health Hospital. These included at the time the only child mental health beds from New York to Worcester.
- Norwood Hospital: Flooding caused a closure of the hospital in June 2020. Reopening plans do not include a replacement for the hospital’s mental health unit.
- In 2021, Good Samaritan Medical Center announced plans to permanently close its inpatient detox unit, located in Foxborough. DPH found it to be an essential service, and the company then issued notice that it was closing anyway.
- In 2017, UMass Memorial Medical Center closed 13 psychiatric beds and then opened with US HealthVest a standalone for-profit mental health hospital.
- Vibra Hospital in Springfield, a psychiatric facility, nursing home behavioral health unit and a long-term, acute care services, closed in 2017.
- The state closed 125 of 170 beds at Taunton State Hospital in 2012.
- Westborough State Hospital, a mental health facility, closed completely in 2010.
- In 2010, UMass Health Alliance Burbank Campus closed a 15-bed inpatient psychiatric unit.
- In 2009, Cambridge Health Alliance closed 60 of 127 mental health beds at Whidden Memorial Hospital.
In addition, a December 2021 report by the Massachusetts Health and Hospital Association and Massachusetts Association of Behavioral Health Systems showed that psychiatric units and hospitals in Massachusetts had taken at least 154 mental health beds offline solely because of staffing needs within the previous 10 months.
“Patients are losing mental health care in their communities because our healthcare system is failing them,” Murphy said. “In Massachusetts, after all we have learned about mental health and the effects of trauma, this is an absolute disgrace. Patients should be getting more high-quality care near where they live, not less care many miles away because a hospital CEO decided profits and executive pay are more valuable than caring for the most vulnerable members of our society.”
Staffing Crisis and Mental Health
Just as the COVID-19 pandemic is no excuse for the overall caregiver crisis, it is no justification for not having enough staff in place to care for patients with mental healthcare needs and comorbidities. As WBUR has documented, there is not a shortage of nurses in Massachusetts. Rather, there is a shortage of nurses willing to work under the current conditions at the bedside.
“The poor staffing conditions that have affected mental healthcare did not start with the COVID-19 pandemic,” Murphy said. “For years, the hospital industry has been exploiting nurses and other healthcare workers by overburdening them with patient assignments and forcing them to work overtime. Hospitals increasingly use just-in-time staffing models, scheduling barely enough nurses to be able to move patients through a revenue-generating system. This approach maximizes profits and leads to growing executive pay. It absolutely fails nurses who are trying to fulfill their professional and moral obligations to provide safe, high-quality patient care.”
Nurse Survey Results Show Understaffing Impact
- 55% of nurses in the 2022 State of Nursing in Massachusetts survey said understaffing was the biggest obstacle to providing quality care, and particularly for newer nurses, with 68% of nurses with 0 to 5 years of experience saying understaffing is the biggest obstacle they face.
- The number of RNs who said they do not feel that they have enough time to provide patients with the care and attention each one needs jumped to a record high of 71%, up from 60% last year.
- The percentage of nurses who said this year that the overall quality of care in Massachusetts hospitals has gotten worse (83%) is higher by nearly 30 points than any other year.
- Almost two-thirds (64%) of nurses said inadequate pay or benefits is a major challenge. This response is up from 48% reporting lack of pay or benefits in 2021 and 27% in 2019 – a 37-point increase in nurses having a concern about pay and benefits over three years.
- 33% of RNs reported planning to leave nursing sooner than originally planned. Among newer nurses with 0 to 5 years of experience, 37% are planning to leave sooner – the highest percentage of any experience group.
Staffing Improvement Efforts of MNA Nurses and Healthcare Professionals
- For decades, the MNA has advocated for safe staffing levels and enforceable patient limits at the local, state, and national level. The impact of how many patients a nurse is assigned at one time is one of the most studied topics in healthcare. Voluminous peer-reviewed evidence shows maintaining a safe patient limit helps protect the quality of patient care, including by reducing avoidable re-admissions.
- MNA legislation entitled The Workforce Development and Patient Safety Act would examine current nursing practice, including the impact on quality of patient care, the makeup of the current nursing workforce, and future needs of nursing care in the state.
- Across Massachusetts, MNA nurses and healthcare professionals work together as union members to negotiate improved staffing levels, wages, benefits and working conditions. These are key to recruitment and retention of caregivers.
Highlighted MNA Solutions Regarding Mental Healthcare
- The Commonwealth should designate an agency or department to collect comprehensive information on all aspects of mental healthcare.
- The Commonwealth should streamline overlapping responsibilities of Departments of Public Health, Department of Mental Health and the Department of Children and Families to facilitate agency accountability.
- To ensure that profitability is not the only factor in maintaining essential health services, the state should have the legal power to mandate the establishment or maintenance of “essential health services.”
- Improve and expand access to a 24/7 centralized bed search tool to find appropriate placement quickly.
- Require parity for mental health reimbursement rates. **A bill passed by the legislature last summer takes steps to address MNA solutions 4 and 5, though it has yet to be implemented.
- Establish criteria for distance traveled to access “essential health services.”
- Establish Intensive Stabilization and Treatment Units within the state system for highly assaultive patients who board longer due to a lack of available placement.
- Establish an ED Diversion program for high acuity, dual diagnosis patients to decrease boarding and provide appropriate care while waiting for permanent placement.
- The state should require comprehensive workplace violence prevention programs at all healthcare facilities.
- Promulgate regulations requiring staffing levels and the removal of other procedural barriers preventing transfers and admissions on weekends.
Founded in 1903, the Massachusetts Nurses Association is the largest union of registered nurses in the Commonwealth of Massachusetts. Its 25,000 members advance the nursing profession by fostering high standards of nursing practice, promoting the economic and general welfare of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Legislature and regulatory agencies on health care issues affecting nurses and the public.