Gotham Gazette

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It Could Take Years to Restore Hospital Psychiatric Beds Statewide, Records Show

Gov. Hochul talks health care (photo: office of Governor Kathy Hochul)

It could take years and tens of millions of dollars for upstate hospitals to restore more than 200 psychiatric beds that were shuttered in recent years, owing to major operating deficits and an industry-wide staffing shortage with no end in sight, according to records obtained by Gotham Gazette.

The delays throw a wrench in Governor Kathy Hochul's plan to restore 1,050 psychiatric beds that had been closed or repurposed statewide during the pandemic – a top priority since her first State of the State address in January 2022, and a key pillar of the $1 billion "continuum of mental health care" she pursued in the state budget.

The beds have become an increasing focus for city and state leaders as the pandemic has brought untreated severe mental illness further into public view, exposing bottlenecks in the mental health care infrastructure caused in part by decades of divestment.

There are 5,780 inpatient psychiatric beds in use in general hospital settings – known as Article 28s for the state law that regulates them – and behavioral health clinics across New York, often the first point of contact for people experiencing a psychological or substance use crisis. Another 3,300 long-term beds are in state-run psychiatric institutions.

Mandatory plans submitted by hospitals to the New York State Office of Mental Health (OMH) and reviewed by Gotham Gazette after a Freedom of Information request describe a near universal struggle to staff inpatient psychiatric units across the state, from Long Island to Buffalo, Manhattan to the Mohawk Valley. The records show that in order to continue admitting people with severe mental illness, many hospitals are relying on expensive travel nurses and physicians, straining resources.

Upstate hospitals, like their counterparts in New York City, are seeking millions of dollars from the state to help pay for personnel and renovations to bring units up to code, many of which had been repurposed as medical beds at the height of the pandemic. Most measure the length of time it will take to onboard beds in months and years and long-term construction timetables.

The hospital plans are a response to a January 10 ultimatum from OMH and state Health Department brass, requiring facilities, under threat of sanction, to restore any non-operational beds in their licensure by April 1.

"The directive to immediately reopen the remaining six beds is currently impractical and unsafe for both patients and staff," wrote one hospital administrator in a letter to OMH Commissioner Ann Marie Sullivan. Another said it would "bankrupt the hospital."

Gotham Gazette first reported that hospitals statewide were on track to blow the state deadline because of workforce shortages and large capital needs, particularly in New York City, which accounts for roughly half of the shuttered beds. But the new documents reveal for the first time the extent of those challenges for hospitals in some of the most remote corners of the state, where beds are few and far between. The reports show similar pressures to those faced by their New York City counterparts – whose plans were also obtained by Gotham Gazette and first reported by Politico – albeit reflected through the prism of distance and scarcity unique to much of upstate New York.

The state ultimatum was part of a campaign from the Hochul administration to induce hospitals to bring beds online. But the responses show most facilities have been in coordination with OMH on their bed capacity before and after the January 10 ultimatum letter. In several cases, beds were closed for years prior to the pandemic through planned downsizing in partnership with OMH.

Last year, Hochul and the Legislature allocated $55 million to increase Medicaid reimbursement rates for the Article 28 psychiatric beds. They also invested an additional $9 million in tuition assistance to build the healthcare workforce. And earlier this month, Hochul announced the first awards under a $4 million scholarship program for SUNY and CUNY students pursuing careers in mental health care.

This year, Hochul is seeking state legislation to increase fines up to $2,000 per day for hospitals operating below their licensed capacity of psychiatric beds.

"It starts with getting more patient beds, more psychiatric beds back online, because right now we have 3,200 New Yorkers struggling with mental illness or addiction who are living on our streets and in the subways," Hochul said in a February 2 speech about her mental health agenda, which also includes more long-term beds in state institutions, supportive housing, and outpatient services.

Despite greater funding, more than 600 of the 1,050 previously offline beds remained out of service this spring, with close to 300 of them in hospitals outside New York City. Within the city, more than 300 psychiatric beds were offline as of March, with the largest single provider – New York City Health + Hospitals, the public hospital network – scheduled to reopen 200 by December at a cost of $700 million.

“Since Governor Hochul took action to restore psychiatric hospital beds taken offline during COVID, hospitals have developed plans to bring a majority of the repurposed psychiatric beds back online," wrote OMH spokesperson James Plastiras in an email statement to Gotham Gazette.

"Governor Hochul's FY24 Executive Budget proposes increased financial penalties for hospitals that are not making a good faith effort to bring beds back online, and OMH is in active conversations with Article 28 hospitals on how best to achieve compliance," he said.

Since September, 213 psychiatric beds have come back online statewide, with another 300 expected by January 2024, according to Plastiras. He would not say whether any hospitals had been penalized, in the form of fines or other enforcement action, for not meeting their licensed capacities.

O​n Thursday, Hochul announced a $229 billion "conceptual agreement" with legislative leaders on the state budget, including $1 billion for mental health care.

​"​Too many people can't get the care they need, and for too long we've underinvested in mental health," ​Hochul ​said. "​Today marks a reversal in our State's approach — a monumental shift.​"

​"​That'll include investment to create 1,000 inpatient psychiatric beds to serve more than 10,000 New Yorkers a year​," she said.

Upstate Challenges
Upstate behavioral health systems have seen increasing strain in recent years. Closures in past decades due to low demand in rural parts of the state have come back to bite those communities, the records show.

In the new reports, written over the past three months, several hospitals described seeing high demand for psychiatric services but lacked the configuration or staff to admit patients, leaving people stranded in emergency departments. And a lack of residential and outpatient services in upstate communities has drawn out the length of time individuals are held on hospital psych wards, in some cases for months, according to the documents.

Hospitals have also seen an exodus of mental health workers in recent years as burnout and non-competitive pay push them into other jobs and fields. Some facilities have been left with a single psychiatrist to manage more than a dozen cases with a skeleton support staff.

Almost every one of the 19 hospital plans reviewed by Gotham Gazette cited the need for both new staff and renovations to remove ligature risks that can be used for self-harm – a critical danger for the inpatient psychiatric population, many of whom are experiencing acute psychosis, depression, or anxiety.

BryLin Behavioral Health Hospital in Erie County, for example, is certified for 84 psychiatric beds with the ability to bring 59 online by April 1, according to Jerri Ritter, vice president of patient care services, in a February letter. The center would have to renovate four bathrooms in order to meet requirements from the Facility Guidelines Institute, a nonprofit that promulgates standards for hospital design and construction. In total, BryLin estimated it would cost $5.6 million in new salaries, capital improvements, and IT upgrades to bring the beds into operation.

BryLin's letter also offered insight into the difficulties of recruiting staff. Of the 265 applications the hospital received for nurses and mental health technicians, only 35 were offered a position and only 16 accepted. Only three out of every five applicants qualified for an interview, according to the letter.

Thin Staff
Glens Falls Hospital, part of Albany Med Health System, has 30 licensed psychiatric beds but since August the hospital has not been able to fill more than 24 beds due to short staffing, according to its report to OMH.

The hospital recently lost a full-time psychiatrist and now has only one doctor for its entire inpatient operation. It relies on per diem physicians to cover nights and weekends. More than half the nurses on the psychiatric unit are also hired from agencies on a temporary basis. In 2022, the system spent $3.3 million on per diem doctors and nurses, close to four times its per diem spending in 2019 before the pandemic.

To staff the full 30 licensed beds (just six more than at present), Glens Falls estimates it would need to hire a full-time psychiatrist, two full-time RNs, and more than three other technicians and support staff.

"We have been actively recruiting for these positions since 2020, in other words, prior to the pandemic, with limited success," wrote President and CEO Paul Scimeca on January 24. "The availability of locum psychiatrist and agency RN's is also very limited."

"There are some with whom we had contracted with and then needed to release due to quality-of-care issues," he added.

The dangers of the job add to the recruitment challenge. "As I sit here composing this response, there have been three 'Code Grays' called seeking immediate help for a behavioral health patient who is threatening staff," Scimeca wrote. "This happens all day, every day. This is an acute dangerous population and patient and staff safety is critically important and a constant challenge."

The need for beds at Glen Falls is indeed great. On the day of Scimeca's writing, the hospital's seven-bed crisis stabilization unit was at capacity, forcing two patients to be seen in the Emergency Department. Eight of the nine patients that day were children, aged 8 to 17, one of whom had been waiting nearly two weeks for a more appropriate placement at another facility, according to the report.

Long waits in what are meant to be temporary crisis relief units are frequent as providers struggle to find treatment placements in long-term facilities or community-based programs. Two adolescents were recently admitted to Glen Falls Hospital for 84 days and 117 days, respectively, while they awaited beds in a residential facility, according to the report.

The workforce shortage has pushed the doctor-to-patient ratio higher and stretched hospital psych wards to their limit across upstate New York.

St. Peter’s Health Partners, a Capital Region hospital licensed for 60 psychiatric beds, had 13 beds offline in late January. The only psychiatrist on the geriatric unit at the time was seeing 16 patients a day.

St. Mary's Healthcare reduced its capacity from 20 beds to 10 beds when its clinical director and psychiatric nurse practitioner resigned, leaving one psychiatrist treating ten patients. On January 9, St. Mary's explained the decision to cut bed capacity in a letter to the OMH Field Office, which was "received and acknowledged," according to the hospital's bed plan. A day later, OMH issued the ultimatum to hospitals.

The High Cost of Psychiatric Care
Most of the inpatient psychiatric programs face significant operating deficits and many hospitals lack capital funding to build new units.

Erie County Medical Center, one of the biggest behavioral health care providers in the Buffalo metropolitan area, is licensed for 160 beds, with 136 open and staffed. ECMC estimates it will take at least two years to finish construction on a 24-bed unit, whose planned remodeling was stalled by the onset of the pandemic. To meet state and federal safety regulations, the patient area must be "completely renovate[d]," from the plumbing to the doors, according to its report in February. But first ECMC must secure roughly $8 million through the state and, once construction is completed, fill nearly 60 staff positions.

The financial strain caused by the pandemic has made that all but impossible.

"Currently, the pandemic has significantly reduced ECMC’s days of cash on hand, leaving ECMC in severe financial hardship and only with enough capital dollars for maintenance," the report reads.

One hospital, Niagara Falls Memorial Medical Center, is projecting a $25 million operating deficit in 2023, and potentially millions of dollars more to bring psychiatric beds online. But the added expense would "bankrupt the hospital and seriously jeopardize our ability to continue to operate 28 existing inpatient behavioral health beds," warned President and CEO Joseph Ruffolo in a January 23 letter.

Even with the state's $55 million Medicaid boost, the cost of keeping an inpatient bed open often outpaces the state's reimbursement rates, according to hospital administrators. Erie County Medical Center's inpatient units, for instance, lose roughly $15 million annually because of the discrepancy between costs and reimbursement from the state, according to its letter to OMH.

Design Flaws
The configuration of beds and the unique needs of the psychiatric patient population has further tied administrators' hands.

Nassau University Medical Center, on Long Island, is licensed for 128 beds. Currently, an 11-bed adolescent unit is shut down, and a 19-bed so-called forensic unit – for people who entered the system through the criminal legal system – is down to 15 beds out of safety concerns "due to the acuity" of the population.

According to a letter in January, all 26 licensed beds at Albany Medical Center are online but logistical constraints mean they aren't always occupied. The psych unit contains no single rooms meaning patients are either doubled-up, or quadrupled up.

"If there are patients that cannot safely have a roommate, many of the doubles often become singles," wrote Kara Ritschdorff, director of hospital regulatory affairs. "This scenario predates the COVID pandemic and is a flexibility critical to ensuring patient safety."

"If it is the Office’s plan to monitor compliance via the daily OMH Bed Availability survey…we would strongly suggest that the survey undergo revision to allow facilities to explain why total bed availability may not reflect licensed capacity," Ritschdorff wrote. "In addition to safeguarding facilities from unnecessary enforcement actions, it will also allow the Office a clearer picture what is truly happening within the inpatient setting."

Years in the Making
Some facilities have been operating below capacity for years, in some cases decades, prior to the pandemic.

Rochester Regional Health, is licensed for 104 beds across four hospitals but only has 70 in operation. That is only five fewer beds than the system had online in 2019, before the pandemic, according to the plan sent to OMH. The bulk of those have been offline at least since 2013, when RRH shuttered 20 beds "in collaboration with the local governmental unit and the local NYS OMH field office."

Last year, RRH submitted a $9 million grant application to the Department of Health for facility improvements, including expanding inpatient psychiatric beds, that had yet to receive a determination at the time of its letter.

Another example is Bassett Medical Center in Cooperstown, which has been operating with only fourteen psychiatric beds, six fewer than listed in its operating certificate. That arrangement predates the pandemic, having begun a decade ago when the hospital remodeled its units – but the inaccurate licensure was only discovered when the OMH ultimatum was issued, according to a January 24 letter. As a remedy, administrators plan to apply to have the six beds removed from Bassett's certificate altogether.

Similarly, Mohawk Valley Health System has been operating far fewer than its 50 licensed beds with plans to restore some but not all of them. MVHS already has conditional approval to remain at a lower level, part of an existing plan to relocate its two hospitals into a single new facility, according to its letter.

Strong Memorial Hospital has been operating 83 inpatient psychiatric beds, ten below the number listed in its operating certificate, since 1996, when its occupancy rate was 75% or below. In order to maintain its capacity and adhere to pandemic protocols, Strong Memorial leased 11 beds in nearby Rochester Psychiatric Center, a mid-sized state-run institution. The hospital is renovating a unit to restore the ten closed beds, which is expected to be completed in early 2024.

UPMC Chautauqua has had 30 beds, 10 fewer than licensed, after OMH approved a plan to keep them shuttered in 2019, according to its report. Staffing issues required it to close five more beds in October 2021, which were reopened in January. The letter notes that a new addition to the facility built in 2019 with OMH approval prevented the construction of a new psychiatric unit.

"Therefore, there is not capability to expand the unit or the structure," wrote Cecil Miller, vice president of operations.

by Ethan Geringer-Sameth, reporter, Gotham Gazette

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