Knight Science Journalism Fellowships at MIT Medical Evidence Boot Camp 2013Gary Schwitzer
This was, I believe, the fifth time I've been asked to speak at this event in Cambridge. Other speakers: Drs. Steven Woloshin and Lisa Schwartz of Dartmouth, Dr. Barry Kramer of NCI, and Dr. Marty Makary of Johns Hopkins.
My talk to University of Wisconsin event, "Science Writing in Age of Denial"Gary Schwitzer
This is an amended version to reduce file size to allow it to fit on SlideShare.
My main theme was news coverage of screening tests that emphasized only benefits while denying/ignoring/minimizing evidence of potential harms.
Clinician’s Research Digest, An APA Journal – Supplemental Bulletin 39, “Improving Access to Behavioral Healthcare Services: The Georgia Crisis & Access Line,” part of a series on research-informed day-to-day clinical practice.
Knight Science Journalism Fellowships at MIT Medical Evidence Boot Camp 2013Gary Schwitzer
This was, I believe, the fifth time I've been asked to speak at this event in Cambridge. Other speakers: Drs. Steven Woloshin and Lisa Schwartz of Dartmouth, Dr. Barry Kramer of NCI, and Dr. Marty Makary of Johns Hopkins.
My talk to University of Wisconsin event, "Science Writing in Age of Denial"Gary Schwitzer
This is an amended version to reduce file size to allow it to fit on SlideShare.
My main theme was news coverage of screening tests that emphasized only benefits while denying/ignoring/minimizing evidence of potential harms.
Clinician’s Research Digest, An APA Journal – Supplemental Bulletin 39, “Improving Access to Behavioral Healthcare Services: The Georgia Crisis & Access Line,” part of a series on research-informed day-to-day clinical practice.
Crisis Now Business Case - Update for NASMHPDDavid Covington
In February 2018, shared this presentation on the NASMHPD monthly update call on the history, context and future development and recommendations for Crisis Now.
The Arizona Crisis Now Model: AHCCCS OutcomesDavid Covington
In 2016, the National Action Alliance for Suicide Prevention published “Crisis Now: Transforming Care is Within Our Reach.” Alignment with these practices cuts cost of care substantially, reduces the need for psychiatric hospital bed usage, ED visits and law enforcement overuse; resulting in better health and declines in suicide rate, justice system involvement/ incarcerations and psychiatric boarding. These challenges are simply greater than previously acknowledged, but the Washington State supreme court ruling on the unconstitutionality of boarding, the suicide death of Virginia State Senator Creigh Deeds’ son, the insistence of hospitals nationwide about the costs and safety and the series of violent incidents from Columbine forward are changing the expectations. These innovative approaches pioneered under the leadership of Arizona Medicaid are now being replicated throughout the US.
In 2016, the National Action Alliance for Suicide Prevention published “Crisis Now: Transforming Care is Within Our Reach.” Alignment with these practices cuts cost of care substantially, reduces the need for psychiatric hospital bed usage, ED visits and law enforcement overuse; resulting in better health and declines in suicide rate, justice system involvement/ incarcerations and psychiatric boarding. These challenges are simply greater than previously acknowledged, but the Washington State supreme court ruling on the unconstitutionality of boarding, the suicide death of Virginia State Senator Creigh Deeds’ son, the insistence of hospitals nationwide about the costs and safety and the series of violent incidents from Columbine forward are changing the expectations. These innovative approaches pioneered under the leadership of Arizona Medicaid are now being replicated throughout the US.
The Arizona Crisis Now Model: AHCCCS OutcomesDavid Covington
In 2016, the National Action Alliance for Suicide Prevention published “Crisis Now: Transforming Care is Within Our Reach.” Alignment with these practices cuts cost of care substantially, reduces the need for psychiatric hospital bed usage, ED visits and law enforcement overuse; resulting in better health and declines in suicide rate, justice system involvement/ incarcerations and psychiatric boarding. These challenges are simply greater than previously acknowledged, but the Washington State supreme court ruling on the unconstitutionality of boarding, the suicide death of Virginia State Senator Creigh Deeds’ son, the insistence of hospitals nationwide about the costs and safety and the series of violent incidents from Columbine forward are changing the expectations. These innovative approaches pioneered under the leadership of Arizona Medicaid are now being replicated throughout the US.
This is a written program that was meant to help those with bipolar disorder in the greater Kansas City area. This program was presented to several university professors and received outstanding feedback
Althe DiscussionMy proposed service for Bellevue Hospital Ment.docxrobert345678
Althe Discussion:
My proposed service for Bellevue Hospital “Mental health program that focuses on LGBTQIA+ Youth” (NYC Health + Hospitals, 2022,). This program would include counseling that will help them manage stress and depression, suicide prevention, substance abuse, homelessness and other services (Trevor Project, n.d). LGBTQIA+ youth may encounter some “negative health and life outcomes”, so it is crucial for them to have access to these and as many other services as possible (Centers for Disease Control and Prevention, 2020). The negative health and life outcomes LGBTQIA+ Youth experiences are issues with coming out to their friends and or family, social or fear rejection, they may experience violence, some form of trauma as well as inadequate mental or medical care (D’Amore Mental Health, n.d). By offering these services Bellevue Hospital can help with making a difference in the health and social disparities LGBTQIA+ youths face.
My focus on two of the five Ps of health care marketing.
For this program I will use two of the five P’s of healthcare marketing “physicians and patients” (Cellucci et al., 2014). The ones that will be utilizing these services are the patients. This program will focus on supporting the needs of these patients and assures them that they have all the support services available to them. The two of the Five Ps that I can apply my proposal is public and patients. The public health of the LGBTQIA+ Youth population would be affected the most from this proposed service. Such as homelessness, substance abuse and suicide can affect the community. Public health, “aims to improve the health and well-being of a group or a population”, not person (Cellucci et al., 2014).
References:
Cellucci, L. W., Wiggins, C., & Farnsworth, T. J. (2014).
Healthcare marketing: A case study approach. VitalSource Bookshelf version. vbk://9781567936056
Centers for Disease Control and Prevention, (2020, December).
LGBT youth resources.
https://www.cdc.gov/lgbthealth/youth-resources.htm
D’Amore Mental Health. (n.d).
Mental health issues in LGBTQ youth.https://damorementalhealth.com/mental-health-issues-in-lgbtq-youth/
Trevor Project, (n.d).
Mental health: You matter. Let’s keep you thriving. https://www.thetrevorproject.org/resources/page/2/?s=Mental%20Health
NYC Health + Hospitals, (2022, Octobe
r). Community health needs assessment 2022.https://hhinternet.blob.core.windows.net/uploads/2022/10/2022-CHNA-ISP-Report.pdf
Reply to Thread
Sharon Discussion
The proposed service chosen for Bellevue Hospital NYC’s Behavioral Health Department is transcranial magnetic stimulation (TMS). TMS is a treatment for depression for patients who do not respond to other medication and therapies. TMS is a “noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression.” (Mayo Clinic, 2018) The treatment inv.
Steve Jobs attained unprecedented success in business thanks to his holistic approach to innovation. Therefore a holistic approach to homelessness will produce unprecedented results that are beneficial to all. The way we relate to one another is instrumental to our well-being and survival. So we must join forces and work together to reduce and/or end homelessness.
Many argue that holistic strategy (i.e. holistic approach to business) sounds abstract - but the chronic silo mentality in organizations reduces efficiency and contributes to more failure than success in the long run. Moreover, I believe that business must encompass the human experience since it is run by humans for humans. As Plato puts it: “The Part Can Never Be Well Unless the Whole is Well."
Recommendations for Urgent and Emergency Psychiatric HealthcareDavid Covington
NHS Clinical Commissioners and RI International together published today recommendations for urgent and emergency psychiatric healthcare, which resulted from a convening of international experts in crisis care in London in June 2018.
Presentation with Lifeline Director Dr. John Draper and Arizona Medicaid Director Tom Betlach on the Crisis Now model, business case, Retreat facility model and Arizona Medicaid contracting and financing approach/details.
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Crisis Now Business Case - Update for NASMHPDDavid Covington
In February 2018, shared this presentation on the NASMHPD monthly update call on the history, context and future development and recommendations for Crisis Now.
The Arizona Crisis Now Model: AHCCCS OutcomesDavid Covington
In 2016, the National Action Alliance for Suicide Prevention published “Crisis Now: Transforming Care is Within Our Reach.” Alignment with these practices cuts cost of care substantially, reduces the need for psychiatric hospital bed usage, ED visits and law enforcement overuse; resulting in better health and declines in suicide rate, justice system involvement/ incarcerations and psychiatric boarding. These challenges are simply greater than previously acknowledged, but the Washington State supreme court ruling on the unconstitutionality of boarding, the suicide death of Virginia State Senator Creigh Deeds’ son, the insistence of hospitals nationwide about the costs and safety and the series of violent incidents from Columbine forward are changing the expectations. These innovative approaches pioneered under the leadership of Arizona Medicaid are now being replicated throughout the US.
In 2016, the National Action Alliance for Suicide Prevention published “Crisis Now: Transforming Care is Within Our Reach.” Alignment with these practices cuts cost of care substantially, reduces the need for psychiatric hospital bed usage, ED visits and law enforcement overuse; resulting in better health and declines in suicide rate, justice system involvement/ incarcerations and psychiatric boarding. These challenges are simply greater than previously acknowledged, but the Washington State supreme court ruling on the unconstitutionality of boarding, the suicide death of Virginia State Senator Creigh Deeds’ son, the insistence of hospitals nationwide about the costs and safety and the series of violent incidents from Columbine forward are changing the expectations. These innovative approaches pioneered under the leadership of Arizona Medicaid are now being replicated throughout the US.
The Arizona Crisis Now Model: AHCCCS OutcomesDavid Covington
In 2016, the National Action Alliance for Suicide Prevention published “Crisis Now: Transforming Care is Within Our Reach.” Alignment with these practices cuts cost of care substantially, reduces the need for psychiatric hospital bed usage, ED visits and law enforcement overuse; resulting in better health and declines in suicide rate, justice system involvement/ incarcerations and psychiatric boarding. These challenges are simply greater than previously acknowledged, but the Washington State supreme court ruling on the unconstitutionality of boarding, the suicide death of Virginia State Senator Creigh Deeds’ son, the insistence of hospitals nationwide about the costs and safety and the series of violent incidents from Columbine forward are changing the expectations. These innovative approaches pioneered under the leadership of Arizona Medicaid are now being replicated throughout the US.
This is a written program that was meant to help those with bipolar disorder in the greater Kansas City area. This program was presented to several university professors and received outstanding feedback
Althe DiscussionMy proposed service for Bellevue Hospital Ment.docxrobert345678
Althe Discussion:
My proposed service for Bellevue Hospital “Mental health program that focuses on LGBTQIA+ Youth” (NYC Health + Hospitals, 2022,). This program would include counseling that will help them manage stress and depression, suicide prevention, substance abuse, homelessness and other services (Trevor Project, n.d). LGBTQIA+ youth may encounter some “negative health and life outcomes”, so it is crucial for them to have access to these and as many other services as possible (Centers for Disease Control and Prevention, 2020). The negative health and life outcomes LGBTQIA+ Youth experiences are issues with coming out to their friends and or family, social or fear rejection, they may experience violence, some form of trauma as well as inadequate mental or medical care (D’Amore Mental Health, n.d). By offering these services Bellevue Hospital can help with making a difference in the health and social disparities LGBTQIA+ youths face.
My focus on two of the five Ps of health care marketing.
For this program I will use two of the five P’s of healthcare marketing “physicians and patients” (Cellucci et al., 2014). The ones that will be utilizing these services are the patients. This program will focus on supporting the needs of these patients and assures them that they have all the support services available to them. The two of the Five Ps that I can apply my proposal is public and patients. The public health of the LGBTQIA+ Youth population would be affected the most from this proposed service. Such as homelessness, substance abuse and suicide can affect the community. Public health, “aims to improve the health and well-being of a group or a population”, not person (Cellucci et al., 2014).
References:
Cellucci, L. W., Wiggins, C., & Farnsworth, T. J. (2014).
Healthcare marketing: A case study approach. VitalSource Bookshelf version. vbk://9781567936056
Centers for Disease Control and Prevention, (2020, December).
LGBT youth resources.
https://www.cdc.gov/lgbthealth/youth-resources.htm
D’Amore Mental Health. (n.d).
Mental health issues in LGBTQ youth.https://damorementalhealth.com/mental-health-issues-in-lgbtq-youth/
Trevor Project, (n.d).
Mental health: You matter. Let’s keep you thriving. https://www.thetrevorproject.org/resources/page/2/?s=Mental%20Health
NYC Health + Hospitals, (2022, Octobe
r). Community health needs assessment 2022.https://hhinternet.blob.core.windows.net/uploads/2022/10/2022-CHNA-ISP-Report.pdf
Reply to Thread
Sharon Discussion
The proposed service chosen for Bellevue Hospital NYC’s Behavioral Health Department is transcranial magnetic stimulation (TMS). TMS is a treatment for depression for patients who do not respond to other medication and therapies. TMS is a “noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression.” (Mayo Clinic, 2018) The treatment inv.
Steve Jobs attained unprecedented success in business thanks to his holistic approach to innovation. Therefore a holistic approach to homelessness will produce unprecedented results that are beneficial to all. The way we relate to one another is instrumental to our well-being and survival. So we must join forces and work together to reduce and/or end homelessness.
Many argue that holistic strategy (i.e. holistic approach to business) sounds abstract - but the chronic silo mentality in organizations reduces efficiency and contributes to more failure than success in the long run. Moreover, I believe that business must encompass the human experience since it is run by humans for humans. As Plato puts it: “The Part Can Never Be Well Unless the Whole is Well."
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NHS Clinical Commissioners and RI International together published today recommendations for urgent and emergency psychiatric healthcare, which resulted from a convening of international experts in crisis care in London in June 2018.
Presentation with Lifeline Director Dr. John Draper and Arizona Medicaid Director Tom Betlach on the Crisis Now model, business case, Retreat facility model and Arizona Medicaid contracting and financing approach/details.
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Last year, over 45 thousand people died by suicide in the U.S., one person every 11.7 minutes, while over a million people attempted suicide. With suicide rates in the U.S. steadily climbing, suicide remains the 10th leading cause of death in the US, the American Association of Suicidology (AAS) recognizes that the only way to impact this serious public health issue is to draw from scientific research and initiate implementation of effective strategies. We anticipate over 1,500 attendees to this year’s conference in the heart of political advocacy, Washington, D.C, April 18 - 21,
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4. Dr. Michael Hogan, NYS MH
Commissioner (2007-2012)
Officer Nick Margiotta, Retired
Phoenix PD, CIT International BOD
Joy Brunson Nsubuga, RI Crisis
Administrator, NC Crisis Center
Wendy Martinez Farmer, LPC
CEO Behavioral Health Link
Dr. Michael Allen, Professor
Psychiatry & Emergency Medicine
Sarah Blanka, RI Crisis
Administrator, Arizona Crisis Center
6. Psychiatric
Boarding
Seattle Times (2013): Lack of
space forced those
involuntarily detained to wait
for treatment, on average
three days, in chaotic hospital
EDs and ill-equipped medical
rooms. Frequently parked in
hallways or bound to beds,
usually given medication but
no psychiatric care.
Carolinas Healthcare
benchmarked boarding times
in their EDs in 2015 but has
since reduced wait times 50%
from the figure cited.
Law Enforcement
Chappell, D (2013) Policing
and the Mentally Ill:
International Perspectives.
Boca Rotan, FL: CRC Press)
Madison, Wisconsin data
cited by Ruby Qazilbash,
Associate Deputy Director,
Bureau of Justice Assistance,
August 31, 2017 ISMICC
Federal Committee
One study found that 1 in 10 calls for service
involved a person with a serious mental illness
Law Enforcement:
ImpactonPublic Safety
In Madison, Wisconsin, law enforcement found
that behavioral health calls for service take
twice as long to resolve
(3 hours versus 1.5 hours on average)
Disastrous Access to Care Wastes Resources
72 hrs
40 hrs
2-3 hrs
Washington State North Carolina Person without SMI
In 2014, Washington
State Supreme Court
ruled the waits
unconstitutional.
Psychiatric Boarding: Long
Hospital EDWaits
7. 74%
40%
20%
None Visual, Hearing
or Ambulatory
Disability
SMI
Half as likely to be
employed as other
individuals with
disabilities
Finance: Employment
No Disability SMIVisual, Hearing or
Ambulatory Disability
What are the Current Real Outcomes?
Health
Life expectancy data WHO
and NASMHPD, and Disease
Prevalence from World
Psychiatry
Finance
Employment data from
American Community Survey
and NAMI SMI
Community
Nation data from World
Happiness Report (“Someone
to rely on in times of trouble”).
SMI data from AZ Health Risk
Assessments (“Someone to
talk to about problems” and
“Someone invites me out for
dinner/activity.”)
Autonomy
“Prevalence of SMI Among
Jail Inmates” and “Poverty
and Severe Psychiatric
Disorder”
Life for the nearly 10
million people with SMI
in the US has
comparable outcomes
to the average person
in Afghanistan.
98%
90%
57%
Iceland USA SMI in USA Afghanistan
55-65%
Community: Friends&
SocialSupports
Loneliness Increases
Likelihood of Early
Death by 30%
4%
20%
% of Population w/ SMI % with SMI in Jail
3-5x increase Poverty,
Homelessness &
Incarceration
Autonomy: MakingOwnLife
Decisions
15-20%
% of Jail Population w/ SMI
84
79
61
Japan USA Afghanistan SMI in USA
2-3x increase Obesity,
Diabetes &
Cardiovascular
Disease
Health: AvgLifeSpan
54-69
8. People with
SMI
Suicide Risk
According to the American
Association of Suicidology, the 2014
suicide rate for males 65+ was 32
per 100,000, but 51 per 100k for
those over 85.
In 2010, USA Today reported the
US Army suicide rate at 22 per
100,000 but the Fort Hood rate was
47 per 100,000.
The Suicide Prevention Resource
Center (SPRC) reported Alaskan
Native/American Indian males ages
15 to 24 had the highest rate at 28
per 100k. In 2010, USA Today
reported those AN living in Alaska
had a suicide rate of 42 per
100,000.
The SPRC says little can said with
certainty about death rates for
LGBT youth due to limited data
collection. Other research suggests
two three times the national rate.
In 2008, a UK study by Osborn
found the hazard ratio for
individuals with SMI, including
Schizophrenia, to be nearly 13
times the general population. In
2010, King’s Health Partners found
the risk to be 12 times greater
during the first year following
diagnosis of a serious mental
illness.
Violence
While rare, incidents of individuals
with SMI who were untreated being
involved in the tragic deaths of
others have garnered the attention
of our national dialogue.
Thousands Die Alone and In Despair
Suicide Rate: HazardRatiovs.GeneralPopulation
White Males 65+
Veterans/Military
Alaskan Natives/
American Indians
LGBT Youth
In 2013, Virginia State Senator Creigh Deeds told
CNN he was alive to work for change in mental
health. A week earlier, he was stabbed multiple
times by his son, who then died of suicide. This
happened hours after a mental health evaluation
suggested “Gus” needed more intensive services.
Tragically, he was released before the appropriate
care could be found.
Unspeakable Family
Pain: TragicOutcomes
11. New Year’s Day, you are taking inventory on a key product and you have the following number remaining
on the shelf from December. Which is best?
1m
Scenario A
1
Scenario B
0
Scenario C
1
12.
13. Average Wave:
9 Waves Were “Average”
Lowest Wave:
21% of Average
Highest Wave:
Nearly 200% of Average
18. Traditional
Public Inpatient
In the First Model, implement the 50 public sector psychiatric inpatient beds per
100,000 population necessary to meet community crisis needs.
Model #1
20. /100,000
The consensus opinion of an expert panel on psychiatric care estimated the
need as around 50 public psychiatric beds per 100,000 population (Treatment
Advocacy Center).
/100,000
44. Level of Care Beds ALOS Occupy % Readmit
Rate
State Hospital 55 400 95% 0%
COE 215 12 95% 15%
Med-Psych 46 30 95% 10%
Hospital-Based 200 6 95% 15%
New Capacity 1484 20 95% 10%
AGGREGATE 2000 16 95% 11%
AnyBigCity, USA
Pop. 4m
45. What does it cost per year?
AnyBigCity, USA
Pop. 4m
46. Model #2
Crisis Now
In the Second Model, add the principle services of the Crisis Now Continuum: a
Crisis Call Center, Mobile Crisis and Crisis Facility Services
54. In the Third Model, fully deploy the principle practices of the Crisis Now System
and add Crisis Navigator and a 24/7 Outpatient Clinic
Model #3
Crisis Now
71. Calculated from BJA presentation at ISMICC (2017), Madison, Wisconsin data
Saved hospital EDs $37m in
avoided costs/losses
Reduced total psychiatric
boarding by 45 years
Calculated from “Impact of psychiatric patient
boarding in EDs” (2012) (Nicks and Manthey)
Reduced potential state
inpatient spend by $260m
Calculated from Arizona data, 2017
The Crisis Now Difference
Saved equivalent of 37
FTE police officers
In 2016, according to Aetna/Mercy Maricopa, metropolitan area Phoenix law enforcement engaged 22,000 individuals that they transferred directly to crisis
facilities and mobile crisis without visiting a hospital emergency department. What difference did it make?
Improved Crisis Clinical Fit to
Need (CCFN) by 6x
Fire savings just starting.
Vastly outnumbered. Ill equipped. Foraging for resources. The nation’s hospital emergency rooms are the Alamo of mental health access and care. The battle for recovery is lost when individuals in psychiatric and addiction crisis have no where to turn.
According to a recent study of the American College of Emergency Physicians, 8 in 10 ER docs say the mental health system is not working for patients.”
This wasn’t what President John F. Kennedy and the architects of the community mental health approach intended. Crisis was one of the five original pillars of the movement, but only in recent years have states, counties and health plans started to invest in these important supports and services.
I’m not going to present a research model. I’m a clinician with an MBA who has worked many years in managed care. I’m going to present the business case for better crisis.
That’s not to say that I’ll give you my guestimates. We’re going to show our math. Think about this a little like the old Jurassic Park movie. I’ve got a strong set of DNA from the Arizona excavation, but it’s got some holes. “That’s where our geneticists take over!” was the line of the mad scientist behind the T-Rex. We have filled the gaps with research findings and data from other large systems.
Unmet Needs
Michael Schoenbaum in Schizophrenia Bulletin earlier this year showed that young people aged 16 to 30 experiencing first episode psychosis have a much higher death rate than previously thought. He suggests many of these individuals may not even be included in the data set above, despite mortality rates you’d have to compare with 70 year olds in the general population to see similar patterns.
Schoenbaum, M., Sutherland, J., Chappel, A., Azrin, S., Goldstein, A., Rupp, A., Heinssen, R. Twelve-Month Health Care Use and Mortality in Commercially Insured Young People with Incident Psychosis in the United States. Schizophrenia Bulletin, April 6, 2017.
Incoming Call Center Volume Varies, and Varies Widely. If call volume came into centers like a steady flow of water through a pipe, forecasting would not be necessary and planned resources would be simple. Instead, volumes are more like waves at the beach hitting the shore, and each one is different. Think about 15 minute increments being the waves that roll into the beach at the Georgia Crisis and Access Line (May 4, 2015). Between 8am and 5pm those 28 waves varied from the lowest being about 20% of the average and the highest being nearly 200% of the average.
There are also significant variations by day of the week, and season to season.
There are now readily available and inexpensive workforce management software tools that continuously evaluate historic 15 minute by 15 minute data rates to forecast and predict future volumes.
We’ve estimated the volume in this AnyBigCity at 99,000 visits, based upon our volume data in the Phoenix area. We’ve also reverse engineered the TAC 50 bed per 100,000 model and believe it maps very closely to our experience.
The Impact of Psychiatric Patient Boarding in Emergency Departments article from earlier referenced 35% going to inpatient and a cost/loss of $2,264 per person (over the course of an 18 hour average ED wait). 99,000 visits denominator
Bureau of Justice Assistance references the Madison, Wisconsin experience that law enforcement contacts with mental health required 3 hours each. We certainly have many reports of law enforcement being asked to spend much more time, but this seems like a reasonable metric.
There is an assumption among policymakers that psychiatric boarding is the result of a loss of sufficient capacity and there’s a number of beds that would solve the problem. That belies a misunderstanding of the referral patterns and flow that actually occurs.