Shereef Elnahal still has a tough time believing it. University Hospital in Newark — which was overflowing with COVID-19 patients during the state’s surge in the spring — now has only five such patients requiring care.
“We are in a much better place than we were in April,” he said.
But Elnahal, the CEO of the hospital — a position he took after serving as state health commissioner — said University is now the middle of another crisis. One that is having as great an impact on his staff and patients. But one that is not getting nearly as much attention.
University Hospital is being overrun with patients with behavioral health issues.
The hospital’s crisis unit for behavioral health patients is full, which means many such patients now need to take beds in the hospital’s emergency department, which means the hospital has to switch more employees to care for these patients. It’s a vicious cycle.
Elnahal said the surge of behavorial health patients, which has been increasing in recent weeks, can be attributed mainly to one thing: COVID-19.
“The period of isolation that many of us had to experience with the stay-at-home order was tough,” he said. “Going through that process of essentially locking the state down, while it absolutely was necessary to prevent COVID-19 spread, certainly made mental health issues worse for people with preexisting conditions.
“And it probably surfaced mental health issues that may have been underlying or lower acuity for folks and just made them worse.”
The situation only got worse after the state’s initial COVID-19 surge, Elnahal said. The reluctance of many to go to hospitals — and, in the Newark area University serves, the hospital often is the place residents turn for any health care issue — was a contributor, too.
“It’s a combination of that stay-at-home order making things more difficult for people with mental health conditions, but also the effect of just delaying that care,” he said. “With all of our outreach initiatives to the community, we’re finally seeing more folks come in, but a disproportionate number are for behavioral health issues.”
Frank Ghinassi has seen an increase, too.
As CEO of Rutgers University Behavioral Health Care and RWJBarnabas Health’s senior vice president of behavioral health and addictions service line, he has a unique view of the landscape in the state.
Ghinassi said he’s seeing a different type of surge. It’s not just the number of people calling the help line he oversees, but the frequency with which they call it.
This includes the New Jersey Hope line, which in earlier days may have been known as a “Suicide Prevention” hotline.
“We’re getting more people calling who’ve never called before,” he said. “But at the same time, there’s another cohort of people who have called periodically from time to time, who are now calling more frequently, for 10-12 minutes at a time, as if they’re using the line for ongoing support.”
Ghinassi said he’s seeing similar increases in the veterans’ line, where veterans speak directly to other veterans. In both cases, he links it to a post-traumatic stress disorder type of syndrome — one that surfaced recently.
“We suspect that people are now realizing that, after the kind of euphoria of news that things have dropped in the state — and there was kind of this sense that, ‘Oh, thank God, we got through this’ — that the news coming out across the country that COVID is surging back up is a contributor,” he said.
“What we’ve been trying to make them aware of all along is now dawning on people: This is not a sprint; this is an ultramarathon. We are not weeks away from this being over, we are months, if not a year or more. And that I think that’s causing distress.”
Ghinassi feels fortunate. The willingness of the state and insurance companies to ease the regulations around telehealth is helping his groups provide more treatment. Dramatically so, in some cases.
“What we’re seeing across the Rutgers UBHC network is that existing patients are missing fewer appointments,” he said. “We have way less no-shows. In fact, in some of our clinics, volume has actually gone up. But it’s not because we’re intaking a lot of new people. It’s because the people who traditionally had seen us — people who would miss sometimes 35% of their appointments — are there. Our no-show rate has plummeted. It’s down (to) around 15%.
Telehealth has removed barriers, too, Ghinassi said.
“You don’t have to get on two buses, you don’t have to get child care, you don’t have to deal with inclement weather,” he said. “It’s so much easier when care comes to you.”
Ghinassi worries the regulations around telehealth could be rolled back too quickly. And he warns that telehealth is not a cure-all for everyone. He said those with severe mental illness —people who may have longstanding problems, thought disorders, difficulties with reality issues — struggle with telehealth. As does, he said, older populations and those on the autism spectrum.
“I just want to be clear that there are some populations that are left behind,” he said.
Behavioral health visits have issues, too.
Elnahal said those suffering from mental health issues often require one-on-one oversight, even when patients are going to the bathroom. When his crisis unit is filled — as it is now — that means more of his emergency room personnel need to pick up those roles for the safety of the patient, the staff and other patients.
It also may mean an increase in security, as many of these patients present as a danger to themselves and to others.
Solutions are not easy.
As the head of University Hospital, Elnahal knows that his inpatient psychiatric unit is filled. And, as he talks to other hospital CEOs, he knows many are in the same position.
“We have a greater demand for those beds because we’re finding that a number of these emergency room patients do need to be admitted to the hospital and we just don’t have space,” he said. “And that number is growing.
“I think this is a phenomenon that is happening in most places, which is scary.”
As the former New Jersey commissioner of health, Elnahal knows state facilities are not in position to handle more patients, either. They have capacity and staffing issues as well — and most are geared to those needing the highest level of care.
At a time when every hospital in the state has made the ability to treat those with COVID-19 a top priority — a priority that remains high, since most feel a second wave may come this fall — it’s hard to get much push behind the idea of expanding access for behavioral health patients.
“I think we need better investment and better funding into mental health and psychiatric care,” Elnahal said. “That includes getting more psychiatrists into the state with targeted incentives. But it also means increasing the institutional capacity to treat patients with behavioral health issues.”
Elnahal said the state soon may have no choice.
“I fear it’s going to be one of the pieces we see in the aftermath of this pandemic,” he said. “It calls into question our system for allocating mental health beds. Depending on what the data looks like across the state, we may end up asking for another certificate of need call for psychiatric beds.
“But we have to see if these trends are sustained.”
Ghinassi feels the surge of psychiatric care will only continue. Aside from the groups he already has identified, he said he can see these needs playing out in the future for another group: health care workers.
“I worry about the physical health care workforce, the nurses, the doctors, and let’s not leave out the other people who don’t get the hero signs but, without them, we can’t function,” he said. “We are now six months in and very few of them have taken vacations. And they themselves are worried about their families.”
They are worried about the future, Ghinassi said.
“It’s the stress of the unknown,” he said. “I’m a runner and I liken this to when you sign up for a race. You decide whether you’re going to do a 10K, a half marathon, a full marathon or an ultramarathon. No matter which one you pick, there are mile markers. And you know the length of the actual race.
“This is a race nobody really signed up for. And there are no mile markers.”
Elnahal, like all health care executives, shares the concern about the impact this will have on health care workers.
And when he looks at the situation — and the community he serves — he only is confident about one thing: There is no finish line.
“It’s unfortunate that these diseases of despair also intersect with poverty and with communities of color in particular,” he said. “That’s the population we serve here, and we serve them proudly.
“But, for many people in Newark, behavioral health resources are few and far between. So, they end up coming to our emergency room. Of course, we will provide them care. But, in many cases, if they had longitudinal care and follow up in the community, they wouldn’t need to.”
That’s the end game, Elnahal said.
“We talk about wanting to move most of the care into the community and that still remains an important goal, but we have to actually follow through on that and create the outpatient behavioral health services that are accessible, especially to vulnerable communities,” he said.
To reach the New Jersey Hope Line, call 855-654-6735.