Expanding CSUs in Maine would improve care for the mentally ill while saving taxpayer dollars


Within the state of Maine, an ongoing mental health crisis persists even in the era of COVID-19. In lieu of better options, a high volume of individuals with mental health concerns have been arriving at emergency departments (EDs) for years now in need of care, swamping our healthcare system. 

Mental health concerns are the number one reason for unnecessary visits to emergency departments nationwide. Some of these patients are then transferred to inpatient psychiatric units (IPUs), where they sometimes stay for unnecessarily long periods of time.

Unneeded hospitalization of mentally ill patients is detrimental to individuals, hospitals and taxpayers alike. In an effort to reduce inefficient emergency departments and inpatient psychiatric care utilization, Maine’s hospital systems should prioritize funding the construction of several additional crisis stabilization units throughout the state. 

For reference, crisis stabilization units (CSUs) are health care facilities that care for six to 16 patients at a time. CSUs provide a low-intensity level of care for mentally ill clients who do not pose a threat to themselves or to others, and they are most appropriate for patients who do not need medication management. 

These units are staffed 24 hours a day to provide therapy and ensure a safe, quiet atmosphere that allows patients to decompress. CSUs may or may not be a part of hospital networks, and critically, clients can go immediately from their homes to CSUs without checking into an ED at all. Clients may also check themselves out if they no longer want to participate in treatment.

Inpatient psychiatric units (IPUs), on the other hand, are a high-intensity form of psychiatric and therapeutic treatment for individuals who are a serious harm to themselves or others, requiring a comparable or longer than average stay than CSUs. 

IPU stays last an average 10 days, while CSU stays vary from one day to 10 days. They also provide care for patients who require their psychiatric medications be prescribed or re-adjusted. IPUs are typically a branch of a hospital, or they are part of a larger psychiatric hospital. To stay in an IPU, individuals must first be referred from a local emergency department.

Emergency departments are not specifically designed to care for the mentally ill. Patients are provided a safe environment in EDs while remaining in the broader community is not yet safe, or if they are awaiting transfer to an IPU, but emergency care can provide little else for mentally ill clients.

It’s essential to understand that building additional crisis stabilization units throughout Maine would provide a more appropriate level of care for many mentally ill individuals who need help. 

Individuals who end up in the ED with mental health needs are typically either released back into the community after staying in the ED for a few hours (often with little or no follow up), or they remain in an ED room for several days until they can be moved to an IPU. 

Unfortunately, on average, mentally ill patients stay in EDs longer than other patients. Remaining in a sterile hospital room for hours can make problems worse for patients experiencing a mental health crisis.

When clients need to stay at IPUs, they often stay for an unnecessary length of time. Long stays can arise for several reasons. A primary reason is because clinicians believe that although a client no longer needs an IPU level of care, he or she is not healthy enough to function well in their prior environment. 

Clinicians often err on the side of caution when discharging these patients by extending IPU stays. Expanding CSU facilities in Maine would provide a safe environment where IPU hospitals could safely discharge patients, ensuring that recovered individuals do not remain in IPUs for longer than necessary for treatment.

Emergency departments at Maine’s local hospitals have been forced to provide a variety of care that they are not equipped to handle. Broader availability of crisis stabilization units in Maine would allow hospitals to allocate staff resources more efficiently to better serve their patients. 

Many times, EDs have to board mentally ill patients while the hospital seeks a proper site of care. It can be difficult for EDs to board these patients while also caring for others who show up to the ED in need of more immediate treatment.  

In recent years, some Maine hospitals have broken federal law by turning away mentally ill patients, so it is not shocking that some clients have received poor treatment at EDs considering the limited options available in emergency settings. Constructing additional CSUs in Maine would be a great relief to the emergency staff of our local hospitals.

Taxpayers should also be concerned about the over-use of our emergency department and inpatient psychiatric units—hospitalization of the mentally ill comes at a high cost. 

Cost analyses indicate that CSUs are a more cost-effective means of caring for the mentally ill than EDs, and CSUs are also a more affordable option than IPU care. If referring clients to CSUs from their homes could become the norm for low-acuity mental health care, ED stays and some IPU visits could be bypassed altogether, leading to a decrease in Medicaid expenditures. 

After utilizing CSUs,  Iowa and Nevada have seen a decrease in both ED stays for the mentally ill and IPU visits. Massachusetts documented decreased mental health care costs for their Medicaid and Medicare enrollees in just three years after building two additional CSUs. 

Expansion of Maine’s CSU network would give IPUs the option to discharge patients rather than keeping them for unnecessary periods of time. This could facilitate substantial savings in public spending for mentally ill patients who are Medicaid or Medicare beneficiaries. Since Maine expanded Medicaid in 2019, taxpayers need to be more aware of affordable healthcare options for everyone in our state than ever before. 

Hospital networks throughout the US, such as Sinai Health System in Chicago and University of Iowa Healthcare, have already expanded their CSU systems, and Maine’s hospital networks should follow suit. If CSU expansion is too expensive for individual hospital networks, the possibility and cost of public-private partnerships between hospital networks and the Department of Health and Human Services could be explored.

Maine needs to act now to create a responsible system to care for the mentally ill. We’ve waited long enough to re-evaluate how we care for the mentally ill in our communities, and as a result of our lagged response, our system has become inefficient, both in terms of care and cost. 

Mental health concerns are only increasing within our communities, and continuing to ignore the issue will only result in additional stress for the mentally ill, healthcare providers and taxpayers.