PSYCHIATRIC SERVICES IN
DOOR COUNTY

a Needs Analysis

Leadership Door County
Class of 2001-2002

The 2001-2002 Leadership Door County class (LDC), after review of numerous project submissions, chose to conduct a survey that might ascertain if there is need for a full-time psychiatrist in Door County. Currently services are provided one day per week by a Green Bay psychiatrist. In addition, services are provided one day per week by a Green Bay advanced practice nurse prescriber. LDC prepared two surveys, one for medical/mental health/social work professionals and one for those who may have contact with people suffering from mental illness. A total of 156 surveys (79 to service professionals and 77 to non-professionals) were disseminated; 81 (31 professional and 50 non-professional) were returned. An overwhelming 88% of the respondents felt that Door County was in need of a full-time psychiatrist. In accordance with LDC’s goal, the results of this survey will now be provided to the community by mailing to all target respondents and by public media sources.

            The Leadership Door County program ("LDC”) has been educating current and future community leaders for the past twelve years. As each class has done in past years, the twelve members of this year’s LDC class were challenged with completing a class project.

            The LDC mission statement states:

“Leadership Door County cultivates strong leaders of diverse viewpoints, who understand community issues, to serve the volunteer and public sectors. 

“To that end Leadership Door County is committed to:

·        Identifying and strengthening community leaders

·        Enhancing personal and professional leadership skills

·        Strengthening communication between diverse members of the community

·        Providing a stimulating learning environment for participants to better understand community issues

·        Promoting opportunities for service in the volunteer and public sector.”

            With that in mind this year’s class wanted to select a project that would have a positive, far reaching impact on Door County. We were approached with many requests for project possibilities. In discussing each potential project we evaluated what effect the outcome would have on the community, and we decided that we would do a needs assessment study of psychiatric care throughout the county ultimately educating the community on our findings.  

          As a background to this project, it was discovered that there is only one psychiatrist currently serving Door County one day per week. It is also important to note the difference between a psychiatrist and a psychologist. A psychiatrist has medication prescribing authority as part of the realm of evaluation and treatment options. He or she has a medical degree and has served a residency in the specialty area of psychiatry. A psychologist has post-graduate training in psychology, has obtained a doctoral degree, and has worked at a post-doctoral position in his or her chosen specialty area of psychology. However, a psychologist cannot prescribe medications of any kind. This is an important distinction because many people suffering from mental illnesses (e.g. depression, ADHD, addictions, schizophrenia, etc.) are benefited by psychotropic medications that alleviate symptoms and are prescribed by a psychiatrist during the course of treatment. (Note: Physicians, physicians’ assistants, and advanced practice nurse prescribers also have medication prescribing authority.) Door County also receives services one day per week from an advanced practice nurse prescriber who is allowed by law to write prescriptions for psychotropic medications. In addition to this clarification of mental health service providers, it is important to realize that the state certifying board for all Wisconsin counties’ community support programs (the program serving the serious and chronically mentally ill) has advised Door County Community Programs that these patients can only be treated by a psychiatrist.

Method

            In evaluating the best course of action, the LDC reached the conclusion that conducting a survey would be the most useful way to gather pertinent data. Potential survey respondents were selected based on a respondent’s likelihood to be involved with or provide services for members of the Door County community who are benefiting or might benefit from the services of a psychiatrist. The selected recipients of the surveys provided medical, mental health, home health, nursing, nursing home, social work, or pastoral services to community residents. Recipients also included members of law enforcement, medical health facilities administrators, the National Alliance for the Mentally Ill, the Mental Health/AODA Group for the Elderly, and the Child Health Team.

Materials

            Members of the LDC class prepared two surveys: one for medical/mental health/social work professionals (“professional”) and one for recipients who do not specifically provide care for Door County residents (“non-professional”). The survey for professionals requested information regarding: 1) estimated number of patients/clients served in the past twelve months; 2) number of those who currently take some type of psychotropic medication; 3) number of those who would benefit from a psychiatric consultation or referral; and 4) if referrals have been made in the past, what is the average length of time in obtaining an initial appointment with a psychiatrist.

The second survey asked the recipients for their observations regarding what types of mental health issues they are aware of within the community. It also asked them to estimate how many people they knew who might benefit from the services of a full time psychiatrist if one was available. Both surveys asked the recipients if they have experienced or would anticipate potential problems trying to access services of a psychiatrist. They both also asked recipients where they felt the best location would be for a psychiatric clinic.

            The surveys invited any comments the recipient would like to include in their response. The surveys were completed with a section for optional provision of recipient name and specialty area.

Procedure

            LDC class members divided the recipient list among themselves for distribution. In some cases a class member attended business meetings of a target group. In other cases the surveys were mailed or hand delivered. Often recipients were invited to contact a class member if they were interested in a personal interview. A total of 79 professional and 77 non-professional surveys were distributed. Self-addressed, stamped envelopes were provided to all recipients for return of the completed surveys.

Results

            A total of 31 professional and 50 non-professional surveys were completed and returned. Fourteen of the professional respondents identified themselves as medical doctors (four internal medicine, six family practice, one general surgery, two emergency medicine, and one non-specified); an additional three appeared to be medical doctors based on their patient numbers. Seven of the professional respondents identified themselves as mental health/social work providers. These numbers indicated a return of 39 percent of the professional surveys and 65 percent of the non-professional surveys.

            The range of numbers (1,800 to 10,000) provided by the medical doctors in the first question made it difficult to estimate the actual case load of the doctor and what number of patients are actually on psychotropic medications. It appeared that the doctors may have itemized the number of patient visits in twelve months rather than the number of patients on their case load. It is probable that a certain percentage of their patients had more than one visit in a 12-month period. With that in mind their responses to the second question, how many patients are on some type of psychotropic medication, ranged from 15 to 800. Some of the doctors’ responses to question three, how many of their patients would benefit from a psychiatric consultation, ranged from 5 to 200. The remaining doctors estimated from 1% to 15%.

            The mental health professionals who responded reported a total patient load of 710. Of that amount they indicated that approximately 520 were on some type of psychotropic medication. The also reported that approximately 508 would benefit from a psychiatric consultation. It is probable that a portion of the 508 already do consult with a psychiatrist through Door County Community Programs or in Green Bay.

            Non-professional surveys listed a wide range of mental health issues respondents felt existed in Door County. The type and number of issues are itemized as follows: alcohol and/or drug abuse – 20; mood disorders – 18; anxiety disorders – 7; disorders of childhood – 4; personality disorders – 3; psychotic disorders – 6; dementias – 4; domestic violence – 6; sexual abuse disorders – 4; financial abuse of elderly – 1; codependency – 1; and finally, loneliness or isolation – 2.

            With regard to the second question on the non-professional survey, most respondents felt that many people in Door County would benefit from access to a full time psychiatrist. A few respondents disagreed. One felt there was no need for a full time psychiatrist. Some felt that only “a few” or “a handful” would benefit from the availability of full time psychiatric services. Three respondents pointed out that although there may be a need, many residents suffer from “psychiatrist phobia”.

            Twenty-eight of the thirty-one professional respondents felt that there is a need for a full time psychiatrist in Door County; two said no and one didn’t know. Of the fifty non-professional respondents forty-three felt that there is a need for a full time psychiatrist; two clearly did not. Five of these respondents were unsure if a need exists. In summary, 88% of the respondents to this survey felt that Door County needed a full time psychiatrist.

            With regard to location for a psychiatric clinic, 66 respondents felt it should be located at some site in Sturgeon Bay. The remaining respondents recommended other locations.

Quotes from Respondents

·        A local psychiatrist available for crises “could avoid ± 12.5% of hospitalizations. Hospitalizations cost about $575 per day plus transportation costs (double time) and possible jeopardy of public safety taking [law] officers off the street.” Patients requiring this type of hospitalization are sent to Brown County Mental Health in Green Bay. These are expenses billed to and paid for by Door County.

·         “Chronic problem the past 33 years.”

·        “The Board of Directors of the Door County Department of Community Programs acknowledges the overall inadequacy of psychiatric care in Door County and has promoted financial support for expanded service and has expanded services as much as is financially able. We have struggled for years, attempting to respond to the demands of the community. It is our Department’s belief that Door County has such a need as to require at least one full time psychiatrist. There are obvious areas of increased demand for specialization including child psychiatry as well as geropsychiatry. We have done our best to respond to the full spectrum of need. The increased expectations for this kind of specialization is daunting, particularly to a publicly funded program. Our historical commitment to providing psychiatric care is clear.”

·        “My population also still suffers from ‘psychiatrist phobia’.”

·        “Many people are prescribed psychiatric/antipsychotics by their general practitioner.”

·        To the question asking if Door County needs a full time psychiatrist:

“No – along with current resources, a full-time psychiatrist would be helpful, but if I were employing one, I wouldn’t want to guarantee more than three days of work per week.”

“Yes – As a non-primary care [provider], I don’t deal much with this problem directly. But I am surprised at the number of patients I see on antidepressants or other psychotropic drugs.”

“Yes, I do but it may be difficult to support without inpatient services.”

“Yes, the number of psychiatrist per capita on a state-wide average would indicate that our Door County population needs one full time psychiatrist.”

“Yes, it would enhance the quality of care and services in Door County.”

·        “I would like to recommend that the Department of Community Programs, Door County physicians, the Senior Resource Center, Door County Memorial Hospital administration, nursing home administrators, and private counseling agencies initiate a dialogue to discuss future psychiatric care in Door County. We recognize that it would be an awkward blend of public and private funding, providing care for both the insurance and uninsured.”

Demographic and Financial Considerations

            Other statistics pertinent to our survey results include the demographics of Door County residents. According to the U.S. year 2000 census, the total Door County year-round population is 27,961. During the summer months of July and August with inclusion of tourists and summer residents, the number of people in Door County triples. The 2000 census also reported that 18.7% of permanent residents in Door County are over 65 years of age. In addition, the census reported that one in three are considered “elderly”. These figures hold more significance when compared with State of Wisconsin figures. The year 2000 census figures for the state indicates that 13.1% of its population is over the age of 65; one in five is classified as “elderly”. It is generally accepted by most professionals that the older segment of the population requires more medical and mental health services than does the general population.

            Robert Valentine of Counseling Associates of Door County provided the following quick estimate on “break even” numbers for a private mental health clinic: If an on-staff psychiatrist worked 44 billable weeks per year averaging 6 to 7 hours per day, total billable hours would equal $241,000 per year. Support and ancillary services would take about 40% of that amount, leaving approximately $145,000 annual income for the psychiatrist.

            At the present time Door County Community Programs currently pays $145 per hour for the psychiatrist serving Door County one day per week. Last year’s payment to the psychiatrist totaled $71,505 (at $140 per hour). In addition, the more recently hired advanced practice nurse prescriber is paid $80 per hour for one day of services per week. Community Programs estimated that additional funds of about 30% of total wages are expended in support of these service providers.

Discussion

            Some of our survey questions were not specific enough to control responses, thus accurate numbers and percentages of people requiring psychiatric care were difficult to determine. Also, responses do not represent the general population (entire community) or even general target group population (professionals and non-professionals who treat or encounter people with mental illnesses) because not all responses were returned. Whether those who did not respond felt there was no need for additional psychiatric care or did not have the time to respond is unknown.

            Of those who completed the surveys, a “significant” majority expressed concern regarding the current availability of psychiatric care in Door County. In calculating total response rates, 88% clearly indicated the need for a full time psychiatrist. Given that the survey was primarily distributed to and completed by those having professional contact with potential beneficiaries of psychiatric care, it is the opinion of this Leadership Door County Class that their concern warrants the attention of the entire Door County community to the effect of initiating discussion relevant to the feasibility of establishing a local full time psychiatrist. Respondents also noted that there are numerous concerns including: difficulty of recruitment of a psychiatrist; the poor financial reimbursement of psychiatric services by private and federal insurance programs; requests for specific psychiatric care in the specialty areas of pediatrics and geriatrics; and the high cost of seeking psychiatric hospitalization outside Door County.

            In accordance with the goal of our class project, this information will be shared with all professionals and non-professionals in our community as well as any other interested parties. It continues to be our goal to educate the community as to the current status of psychiatric care in Door County as well as the perceived needs professionals feel exists based on their experience providing care to our residents.