At the end of February, a major inpatient psychological unit in Wyoming closed its doors. The PineRidge Inpatient Behavioral Health Unit in Lander had shut down partly due to federal regulations. This has created a domino effect and the outpatient behavioral unit will also close its doors April 5. This leaves a mentally ill population without accessible critical care in northwest Wyoming.
Kris Sturgeon lives in Lander. She has major depression and multiple personality disorder. On the day I met her, she wasn't doing so well.
"I'm in one of my major depressions right now," Sturgeon told me sitting in her living room while her cat, Ace, vied for petting.
She can't get the immediate critical care that she needs because of the recent closure of the PineRidge behavioral health facility.
"I mean, thank God, I'm not suicidal, and I don't have to worry about that but I also know that I can become suicidal very rapidly," she said.
For Sturgeon, the eight to 13 bed unit with psychiatric staff to help the mentally ill was a safety net. She knew she could get help within hours. But now the closest inpatient psych unit is two and a half hours away at the Wyoming Behavioral Institute (WBI) in Casper.
"The last thing I heard is that WBI is full, so it's not an option anyway."
So why did PineRidge close? A press release from the parent company SageWest Health Care said one of the main reasons for the closure was federal regulations to increase the ligature safety of these inpatient behavioral facilities. More specifically, the facilities need to be clear of anything that could be used to attach a cord, rope or any other material for the purpose of hanging. These regulations are directed from the Centers for Medicare and Medicaid Services (CMS).
Mark Covall is the president and CEO of the National Association for Behavioral Healthcare (NABH), which just came out with a report analyzing how regulatory burdens are affecting inpatient psychiatric units.
"CMS decided that the regulations that were in place were not working the way they should," said Covall. "Basically, they put in place a directive saying that all their inpatient behavioral services need to be ligature free."
CMS released two memos, one in December 2017 and the other in July 2018, relating clarifications to CMS' ligature risk policy to surveyors. Covall said the problem with the CMS directives is there is no clear guidance for people who oversee these facilities, who are known as surveyors.
"The changing of interpretation from surveyor from surveyor has wreaked havoc and required some significant changes to the facility that in many cases did not increase patient safety," said Covall.
Covall is conveying that there's a lot of interpretation as to whether or not areas of the facility are safe or not. But regardless some changes have to be made.
SageWest declined to comment. But after speaking to a number of people close to the situation, it seems SageWest decided the cost of updating its facility did not benefit them in the long run.
John Snook is the executive director at the Treatment Advocacy Center, which is a national organization that works to bring awareness to the trend of decreasing inpatient behavioral beds. He said inpatient beds are some of the hardest beds to keep.
"If you are a hospital trying to make money or a rural hospital that is really struggling to make ends meet to keep the lights on, it's really difficult to justify the beds," said Snook.
Inpatient psych beds are expensive and don't really pay for themselves, but Snook said these facilities are really important to the mentally ill.
"When they don't have the beds they need, they just end up in the system that can't say no or jails or homeless shelters," he said.
This is something Scott Hayes is worried about. He's with Freemont Counseling, which is a mental health and substance abuse treatment center in Lander.
"I do worry about it. Ideally, you have someone who needs that level of inpatient care and they need it because their outpatient counseling is not going to cut the mustard," said Hayes.
He said PineRidge closing takes a chunk of availability away and people have to look elsewhere. But there are only four other inpatient behavioral units in all of Wyoming. They are located in Evanston, Laramie, Cheyenne and Casper.
They are also feeling pressure from CMS said Mark Russler who is the director of an inpatient crisis stabilization center in Worland.
"The state hospital is closing down units at a time to put in [an] alarm system in each room," said Russler. "But there's a loss of 14 beds* on each unit until they get all that work done."
But even if the Wyoming State Hospital does the construction to keep up with CMS regulations, Mark Covall said there's a possibility that another surveyor will come in and decide something else needs to be updated or changed because there is no clear guidance from CMS over what is required.
"The surveyors looking at the facilities differently than they did before without any new guidance is a moving target," said Covall.
A CMS representative said some official guidance will be released soon.
No one disagrees that ligature risk is important, but some say there's a limit. Wyoming mental health professionals are trying to look for solutions to divert patients need for an inpatient bed. This includes crisis stabilization centers like the one Mark Russler is director of in Worland. But this costs money as well.
For now, individuals like Kris Sturgeon, who has major depression, will have to find a way to travel at least two hours or longer to an inpatient psych bed where there may not even be a bed available.
*The Wyoming State Hospital is actually closing down one 16-bed unit at a time throughout all renovations. One renovation is currently happening and is planned to be completed by April 19. A second phase to renovate for a ligature free environment is planned to start April 22 and be completed by July 26.