She first called a psychiatric crisis line because her son tried to choke another child at school. He was 3 years old.
When he was even younger, he frequently darted into traffic. The boy argued, aggressively, over the color of the sky with his preschool teachers. At home, he destroyed things and terrorized his two siblings.
“What do the bad weeks look like,” Nicole Desnoyers says of her 10-year-old middle child, Ja-seir. “Running away from home. Destruction in our house. Me having to call the police three or four times.”
Her son often hit, bit and scratched those who disagreed with him or got too close. “He once stabbed a nurse with a pen when she touched him,” she says.
Ja-seir’s diagnoses include disruptive mood dysregulation disorder — characterized by severe, unpredictable bouts of rage, along with attention deficit hyperactivity disorder and general anxiety, Desnoyers says.
He was first hospitalized at age 5 and has been hospitalized multiple times since, including at Providence Behavioral Health Hospital in Holyoke in 2017. Medical and therapeutic personnel there were able to help stabilize Ja-seir for two years, the longest period of relative calm in his short life, according to his mother, who lauds the facility for the help it provided her son and family.
Significant changes to access to such care are now on the horizon.
Mercy Medical Center, which operates Providence, and parent company Trinity Health Of New England plan to end inpatient services in Holyoke by June 30, citing a dearth of psychiatrists and trouble recruiting and hiring qualified staff.
A state review of the plan deemed the inpatient beds an essential service. Mercy was due to submit a more detailed plan to regulators by this weekend, outlining alternatives for maintaining access to inpatient beds. The state has also asked Mercy officials to document its search for psychiatrists.
If the state finds the plan acceptable, Mercy can close the Providence beds — a total of 74 for children and adults. The move would reduce the number of psychiatric beds for children and adolescents in Western Massachusetts to zero. This realm of care has historically been stretched thin to begin with, families and mental health advocates say.
The potential closure punctuates a contradictory public dialogue over the need for increased mental health services for children and teens and the economic tug-of-war between insurance companies and physicians, experts say.
Opponents of the closure argue it’s more of a bottom line issue for Michigan-based Trinity Health, a company with annual operating revenues of $19.3 billion and $27 billion in assets.
U.S. Sen. Edward Markey, D-Massachusetts, has twice called on the health system to reconsider the plan to close the units.
“Providence Hospital provides an essential service for Western Massachusetts, and Trinity Health has a responsibility to these communities,” Markey has said. “I urge the company to redouble its efforts to recruit needed staff, and to provide sufficient reimbursement to recruit that staff, rather than close down these beds.”
Mary K. Orr, a spokeswoman for Mercy Medical Center, said the company will work with the state to help patients access care when inpatient services at Providence end.
“We respect and appreciate Senator Markey’s position,” she said. “Unfortunately, the shortage of psychiatrists has reached a critical point, preventing our future ability to provide safe, quality care to our patients.”
Experts in the psychiatric field say many health care providers struggle with reimbursement parity in behavioral health treatment compared to medical treatment. Despite the state’s progressive posture, insurance reimbursement rates for mental health treatment in Massachusetts tend to be about 60% lower than medical care, according to the American Psychiatric Association.
The chasm between the two treatment worlds has widened more than 20 years after Congress passed the Mental Health Parity and Addiction Equity Act in an effort to close it. Trinity Health made its announcement one day after state Attorney General Maura Healey announced a $1 million settlement with three insurance companies for allegedly violating the act by creating barriers to mental health services.
“Mental health needs have never driven the system,” says Dr. Jeffrey Geller, president of the American Psychiatric Association. “Reimbursement and who pays the bill have driven the system.”
He adds, “If we are going to manage teen suicide, if we’re going to manage escalating drug overdoses, we need to have a system which we don’t have in the U.S. and which we’ve never had — where needs come first.”
Orr describes the shortage of inpatient providers as a nationwide problem and says the challenge is “not unique to us or our area.”
Recruiting efforts for Providence failed to find board-certified psychiatrists to fill positions, according to Orr, and relying on temporary or per diem physicians is not sustainable. Using temporary workers “forces us to make decisions as to whether we can safely provide care on a week-to-week or even day-to-day basis — which is disconcerting for patients, staff, and the community as such staffing could be detrimental to patient safety and quality,” she says.
Parents like Desnoyers say they are aware of the reimbursement struggle for mental health providers, but argue it pales in comparison with the struggle to find care for a child grappling with mental and emotional health.
“They don’t get reimbursed enough. I get it,” Desnoyers says, “but we desperately need these services here.”
When her son sank back into a behavioral crisis last year, she pushed to get him re-admitted to Providence. The center refused him, according to Desnoyers. Instead, he “boarded” at Baystate Medical Center for three weeks. Hospital officials attempted to send Ja-seir home, but she refused to take him. It’s not that she didn’t want him; she says she didn’t feel it was safe.
He finally found a placement in Westborough, more than an hour’s drive from here. Desnoyers struggled to make family meetings as she and her partner, who works full-time, share a car. Ja-seir is currently in a local group home as a “step-down” measure.
Amid the COVID-19 pandemic, she has not been allowed to visit her son. They are allowed one 20-minute Skype call per day. His tiny face appears on her iPhone and she asks him about his day. She has not been able to hug her son in two months.
Jamie Guerin of Northampton poses for a photograph while her 14-year-old daughter sits on a bench in the background. (Hoang 'Leon' Nguyen / The Republican)
Jamie Guerin is similarly distraught over the planned end to inpatient services in Holyoke. Her 14-year-old daughter received treatment there after a suicide attempt late last year.
The girl remained in a locked pod at Cooley Dickinson Hospital in Northampton, where the family lives, for a week as doctors urged her to go home with a “Scout’s honor” pledge to stop acting out or trying to hurt herself, says Guerin.
“Their argument was: There’s no bed, there’s no bed, there’s no bed … and they kept trying to triage her out of there on a teenager’s promise,” Guerin says. “There wasn’t a bed available in the entire state … and she was considered a high-risk, low-profit patient.”
Guerin refused to take her daughter home and slept on the floor or in a broken recliner at the hospital for a week. Eventually, the state Department of Mental Health got involved and began advocating for her daughter. They helped secure a bed at Providence.
“She loved the staff, she loved the groups, she loved the structure and she loved being with the other children there. She really formed some great relationships,” Guerin says. “We heard about the closure shortly after she came back home. It was very fresh. She was like ‘What’s going to happen to all the kids?’”
Guerin says her daughter knows of three teens who have taken their own lives over the past year. “This is increasing at such an alarming rate,” she says. “Our culture and our society need a lot of work, but we need more beds, not less.”
Her daughter was ultimately “sectioned” by the state — a court-driven process that deemed the girl a danger to herself — before she was able to secure the bed in Holyoke.
Among Trinity Health’s arguments pushing back on criticism of the planned closure is that families here will have access to its facilities in and around Hartford, Connecticut. While Geller would not comment on Trinity Health specifically, he says he believes that alternative is flawed, at best.
For one, those court-ordered “sections” that helped Guerin’s daughter secure a bed in the first place hold no value or authority outside Massachusetts, he said. And, greater distance creates greater hardships for families.
“Particularly in child psychiatry, we’re talking about acute care. Family members are active individuals in that treatment. They go to team meetings; family contact in terms of visiting is crucial,” Geller says. “The farther the distance … the greater the burden is going to be.”
Statistics cited in the “Milliman Report,” a gold standard look by a think tank into the parity issue, show long-distance placements for children needing inpatient psychiatric care in Massachusetts nearly doubled between 2013 to 2017.
The state said the revised plan submitted by Mercy and Trinity Health must address “methods of transportation for patients who need access to inpatient care after the closure of the hospital as well as family and friends who wish to visit and will now have to travel out of the Holyoke-Springfield area.”
For parents like Desnoyers, who fears her son will need inpatient care for the rest of his life, the landscape fills her with anxiety. “This is a scary, ugly system,” she says. “And none of us wants to be in it.”