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Hospitals in Missouri, including those within the Mercy and SSM Health systems, are struggling to care for an influx of unusual patients: those who don't need to be hospitalized.

Dozens of foster children and adults with intellectual and developmental disabilities are languishing in psychiatric units, medical wards and emergency departments because they have nowhere else to go.

What was once an occasional issue escalated during the pandemic as employees of state-run facilities serving these populations left their jobs. As a result, the number of appropriate living options dwindled. Now, in a typical scenario, a teenager or adult with behavioral issues will show up at an emergency department, and once they're stabilized, ED staff can't find an appropriate placement for them.

For the adults and youth who are affected and the hospitals that are already challenged with overcrowded emergency departments, "it's absolutely an emergency — and a crisis," says Patricia Morrow, executive director of behavioral health for Chesterfield, Missouri-based Mercy. The system has 12 hospitals in Missouri.

Default placement
Over the last year, Mercy hospitals housed as many as 40 adults and a half-dozen foster children, primarily adolescents. Many stay for months, some for a year or longer, in units meant to provide temporary stabilizing care.

For some, their needs are very complex. They may be unable to communicate with words and unable to manage daily activities such as eating and getting dressed. They may be at risk for hurting themselves or others. In some instances, their needs may be so significant that they must be housed alone, taking up spaces designed for several people.

Morrow says a lack of appropriate placement options and supports within the state system is the primary driver of the crisis. That lack, she says, leaves hospitals as the "default placement."

"We already have a mental health crisis across the country, and other patients need psychiatric services," she says. "This has a domino effect in places like our emergency departments and other areas where they need care — and we may not have the capacity to care for them."

Children in foster care who are being housed in inpatient Mercy psychiatric units receive compassionate care and treatment though they are not living normal lives, Morrow says. They are unable to attend school, engage in social activities with peers or be outdoors, all of which she says can have a very detrimental impact on their mental health and development.

"There's a collective sentiment among providers across the state that this is harming children," Morrow says.

It also diverts financial resources that could be used for other hospital needs. Over the past year, Mercy has spent more than $400,000 caring for these nontraditional patients in psychiatric wards, a figure that doesn't include those temporarily boarded on medical floors and emergency departments.

"We do not get reimbursed for most of the care," Morrow says. "So it creates a pretty significant financial burden."

A new normal
St. Louis-based SSM Health is also struggling to absorb the expense of caring for foster children and adults with intellectual and developmental disabilities who remain within the system due to lack of placement options. The system has nine hospitals in Missouri.

The system's hospitals now typically house a half-dozen children and more than three times that many adults. SSM Health loses money each day a patient is boarded, according to Michelle Schafer, regional vice president, behavioral health.

"The cost of boarding patients is very significant," she said.

"Medicaid reimburses us at their standard rates, but that is lower than our actual costs."

For 2023, the Missouri Medicaid per-diem rates range from $1,086 to $2,316, depending on patient needs.

The crisis over housing these patients is not going away anytime soon. "It is definitely the new normal in the state of Missouri," Schafer says.

Schafer predicts things will only get worse, "unless we start working together and thinking about transformational ways to take care of those who are marginalized and suffering."

'Just blew my mind'
Missouri state Sen. Elaine Gannon, R-DeSoto, found out about the situation last year when she heard Schafer testify in a hearing.

"Oh my gosh, I'd never heard of that before, where a patient could be in the hospital for over a year because there's nowhere to place them," Gannon says. "It just blew my mind."

Gannon approached Schafer about forming a committee, with Schafer at the helm. The committee's regular meetings of state providers, members of advocacy groups, and hospital representatives, including Morrow from Mercy, have grown from a dozen members to 30.

As the committee began to strategize, Gannon and others also focused on legislative solutions. Gannon attached to an existing bill a proposal formalizing the committee. In July, Missouri Gov. Mike Parson signed it into law.

"The bill brings the stakeholders together to design a sustainable solution, to identify the gaps and apply resources where and when necessary to address this issue," Gannon says.

The legislation gives the committee new resources. For example, it provides funding for a consultant group to help the committee gather and use data to inform its ideas.

Schafer emphasizes the committee's cooperative spirit. "This is not about blame, this isn't about who isn't doing what," she says. "We have all come together in this crisis to lean in, look together at it through different lenses and solve it."

Bold change
The committee's chief focus is the patients' well-being, Schafer says. Members are exploring not only how to resolve the crisis but also how to prevent it from happening again. Conversations include ideas about how to support foster families, shore up residential care facilities and expand mental health resources. Missouri has more than 13,000 children in foster care, according to the state Department of Social Services website.

Hospitals in other states, including several SSM Health hospitals in Oklahoma, are dealing with similar issues. In Oregon, PeaceHealth, Providence St. Joseph Health and another health system filed suit last fall alleging that the state is forcing acute care hospitals to provide long-term care for patients who have been civilly committed due to severe mental health issues.

As Missouri stakeholders work to hammer out solutions — and it's unclear how long that might take — Schafer envisions the committee's process becoming a national inspiration.

"I really hope for us to have a model for other states that are experiencing the same situation, so that they can come together in a similar way," Schafer says.

She says the committee's work is directly tied to the Catholic mission, pointing to CHA's new vision statement.

"The statement says that, 'We will empower bold change to elevate human flourishing,'" Schafer says. "And I think this hospital situation is a microcosm of what's going to happen if we don't do that."