The nature of the “serious, life-threatening” prescription errors of the troubled mental health center responsible for serving 10 Western Slope counties has put many patients at risk, according to official investigative findings. Nine months.
Despite growing public concern about Grand Junction-based Mind Springs Health and its psychiatric hospital, West Springs, state officials kept June’s findings secret.
The problems were so severe that the state’s Medicaid contractor would not authorize payments for new hospital admissions for three months until Mind Springs agrees to make sweeping changes.
The state investigation found that out of a sample of 58 Mind Springs outpatient clients, nearly half received poor quality of care that was classified as a potential “serious, fatal outcome.” Two people died, although no direct credit for the deaths was given to the care they received.
“If there are any things that have been investigated and problems are found, people have a right to know,” said Wendy Wolf, a Summit County resident whose son has been treated by Mind Springs for more than seven years. “How do we know it’s safe to send our families, our communities, there without public disclosure?”
The Colorado News Collaborative received a June 2021 letter from Rocky Mountain Health Plans, an agreement to manage and pay for Medicaid benefits on Colorado’s Department of Health Care Policy and Western Slope. As part of that agreement, the company is responsible for investigating and holding to account complaints against Mind Springs and two other Western Slope community mental health centers.
Rocky Mountain Health Plans launched its own inquiry last spring, based on information from a whistleblower physician in Mind Springs.
A letter to Mind Springs’ chief medical officer found that a previous spring examination of Rocky Mountain Health Plans found deficiencies in half of the samples from 54 patients in West Springs. Those patients were re-admitted to the psychiatric hospital within 30 to 60 days after discharge between February 2020 and February 2021.
Mind Springs cut outpatient services dramatically in December 2018 after opening a $ 34 million new psychiatric hospital, doubling the number of its inpatient beds from 32 to 64. It now spends almost three times more on hospitalization than other community mental health centers, and its patients are re-admitted at four o’clock. Each time, the payment shows the data.
“If you look at the data, look at the remission rates and follow up after the patient is discharged … Mind Springs Health Hospital is off the charts compared to other psychiatric hospitals,” said David Mock-Lame, Rocky Mountain Health Plan executive, at a recent town hall meeting in Mesa County. “We’re talking a fraction of the redemption rate and the follow-up rate many times.”
The company’s June 2021 letter stated that between February 2020 and February 2021, 58 outpatient customer samples were prescribed high doses of the tranquilizer benzodiazepine, with 52 people concerned about the quality of care provided and 28 (48%) concerned. The poor had to endure “serious, fatal consequences.”
An elderly Mind Springs patient was later discharged from West Springs Hospital with a prescription for high doses of benzodiazepines and other drugs, which, if used together, could cause difficulty breathing, the investigation found. The man’s death was due to respiratory failure, although the investigation could not link him to improper care. Another patient who did not receive follow-up care after being discharged from West Springs died of an overdose of analgesics.
Rocky Mountain Health Plans examined Whistleblower last spring after a doctor at Mind Springs approached the company about Medicaid management, prescribed procedures, lack of peer review and other treatment issues.
It was only when the Department of Healthcare Policy and Financing released a letter outlining the findings of Rocky Mountain Health Plans that its executive director, Kim Bimesteffer, learned that reporters were getting it the other way.
Mind Springs is contracting with the state to care for anyone who is poor or on Medicaid and is facing a mental health crisis in Eagle, Garfield, Grand, Jackson, Mesa, Moffat, Pitkin, Rio Blanco and Routt and Summit. County
In Summit County, where the community has expressed dissatisfaction with Mind Springs’ services, authorities found the crisis concern so low that they canceled three contracts with Mind Springs and turned their backs.