In the middle of March, it looked as though something was happening at Unit 2700, the inpatient chemical dependency program at St. Joseph’s Hospital in downtown St. Paul. Word was that patients, many of whom had been hospitalized for complex detoxification and other medical concerns connected to substance use disorder (SUD), were being discharged from the unit with less than 24 hours’ notice to make space for patients with mental illness who had also been diagnosed with COVID-19.

In the Twin Cities’ tightly knit addiction recovery community, word spread quickly. Unit 2700, with its nearly 50-year history of treating mostly low-income clients requiring complex medical care, has played a key role. While leadership at M Health Fairview had indicated that the program could be on the chopping block since it acquired HealthEast, St. Joseph’s former owner, back in 2017, many observers were startled and disappointed by what they were hearing. Word was that some Unit 2700 patients were moved to non-hospital-based SUD treatment programs in the Fairview system, but others had been released into a variety of less-intensive community-based programs.

Anne Pylkas, medical director of Sage Prairie Clinic, an independent treatment and recovery program for people with substance use disorder (SUD) based in Burnsville, Eagan and Maple Grove, said that two people who had been discharged from Unit 2700 showed up at her clinic in mid-March. The discharged patients were being treated for opioid addiction with the relapse-reducing medication suboxone. “They weren’t done with treatment,” Pylkas said. “They just got kicked out.”

Pylkas asked her new patients for more explanation.

“They said, ‘We were discharged,’” she recalled. “They’d completed just two weeks of treatment to that point. They’ll have to go to another place and get four more weeks of treatment. They told me they were discharged from St. Joe’s because of COVID.”

JJ Johnson, service area director for integrated chemical heath at Avivo, a Twin Cities-based nonprofit providing a range of mental and chemical health support services, said that he got word that Unit 2700 was closing from a friend. “He was getting an interview to be a tech on 2700,” Johnson explained. “They called him and said, ‘We’re closing the program. We’re not hiring anymore.’”

The news was a disappointment, Johnson said, but it wasn’t a surprise. In his opinion, “Everybody knew that St. Joe’s was going to close anyway. Fairview announced months and months ago that they were going to close 2700. COVID finally gave them the excuse to do so, despite community uproar.”

Rik Lundgren, vice president of Minnesota Addiction Professionals and a chemical health counselor in the M Health Fairview St. John’s, said that he became alarmed in mid-March when he started hearing from colleagues that Unit 2700 was going to be converted to mental health. “My understanding is they’ve placed all the people who were admitted for SUD in other community programs and moved people who had been admitted to St. Joe’s for mental health disorders to Unit 2700,” Lundgren said. “What we heard is they were going to change the character of Unit 2700 so that the people there were primarily admitted for mental health disorders. They did say they could make room for people with dual [mental health and SUD] disorders, but that was it.”

Beth Heinz, executive of mental health and addiction services at Fairview Health Services, confirmed that some Unit 2700 patients were moved within the Fairview system earlier this spring to make room for the special mental health/COVID unit while others were discharged into community programs.

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“We have made a unit at St. Joe’s a place for our COVID patients whose primary presenting issue is a mental health crisis,” she said. “In that way we can keep them with our mental health programming and our staff and providers who specialize in mental health and addiction.”

Heinz added that Fairview continues to accept patients with SUD into their programs. “Right now we are taking all patients,” she said. “We have capacity across our system. We had some patients [on Unit 2700] that had residential status. We were able to discharge them into community programs. But we are still absolutely admitting patients with addiction and mental health crises across our system.”

Patient census in St. Joseph’s ED is down by 60 percent, Heinz said. This reality, combined with the reshuffling of patients, could partially explain what happened on the unit, but it doesn’t absolutely signal the program’s closure. “We don’t have the volume right now but we haven’t closed that program,” she said. “We’ve made no decision directionally to change St. Joe’s services at this point.”

She said she wants people to understand that St. Joseph’s is still open for business.

“We recognize that with the public messaging asking people to stay home that people are staying home,” Heinz said. “What I think is a really important message is that if people are having a mental health emergency we will keep you safe. We have capacity to take care of patients.”

There are other indications that M Health Fairview hasn’t abandoned all plans for treating SUD at St. Joseph’s. In January, for instance, the organization renewed its license with the Minnesota Department of Human Services to operate a hospital-based inpatient chemical dependency program.

In a statement, M Health Fairview said, “The COVID-19 public health crisis and stay-at-home orders have reduced the volume of patients seeking mental health services throughout the M Health Fairview system and across the country. Despite the decreased demand, M Health Fairview and St. Joseph’s Hospital remain committed to providing mental health and addiction services. To prepare for the surge of COVID-19 and protect both our patients and our staff from exposure to the virus, we have executed a quick pivot to telehealth for many mental health needs. For patients requiring inpatient care, St. Joe’s currently has 105 MH/CD beds and we are utilizing a cohorting strategy to protect patients from COVID-19 exposure. That has had some temporary changes but nothing long term. These are temporary adjustments to our services; no permanent programmatic changes have been made at M Health Fairview St. Joseph’s Hospital. From telemental health appointments to emergency care and inpatient treatment, M Health Fairview stands ready to serve patients who need mental healthcare and addiction support during the current crisis.”

Community impact

For decades, Unit 2700 has played an important role in Minnesota’s addiction community.

Johnson, who worked as the unit’s director until 2017 (“I was in the first group that got laid off when Fairview took over,” he said), explained that the program has a history of caring for patients who need close medical observation to detox or recover from addiction. Some of those patients included pregnant women with opioid use disorder (OUD) who required 24-hour medical care.

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“St. Joe’s has always taken some of the hardest cases,” Johnson said. “They are a federally recognized opiate-treatment program. That’s a special designation given by the federal government.”

Care for pregnant women with OUD is particularly hard to come by, Johnson said. If St. Joseph’s program were to close, options for women in this situation would shrink significantly. While other addiction-treatment organizations including Avivo offer programs for addicted pregnant women on outpatient and high-intensity residential levels, none are hospital-based, which experts like Johnson say is essential for high-risk pregnancies. This capability and expertise has always set Unit 2700 apart.

“When I was there we had a lot of women who were pregnant come into the program,” he said. “It is the only hospital-based inpatient program in the region.”

Johnson said that until recently, Avivo was able to refer pregnant clients to St. Joseph’s. But this spring, that changed.

“We can’t refer pregnant women to St. Joe’s for an inpatient level of care. We were told by St. Joe’s, ‘There are no beds available, and we’re not taking admissions.’”

Johnson said he finds this turn of events particularly distressing. Even if COVID fears have reduced the number of people seeking care at hospitals, he said, “Pregnant women haven’t ceased to exist. I would think that the need for inpatient addiction care is greater now than ever. If I were pregnant and on opiates and trying to get off, I would much rather go to an inpatient facility than an outpatient program. It’s just that much safer.”

Lundgren said that St. Joseph’s apparent move away from accepting pregnant women with SUD is a significant change from how the hospital had positioned itself just a year and a half ago.

“From a substance use disorder treatment perspective, the most significant thing here is that 18 months ago these folks at St. Joe’s were bragging — and I thought rightly so — about being the only program in the state that was able to admit pregnant women with OUD,” Lundgren said. “The team that they had put together at that point was remarkable. The resources were amazing — they had midwives, they had doulas — it was going to be great. Now, 18 months later, they’re not doing that kind of treatment at St. Joe’s anymore, at least not inpatient.”

The changes at St. Joseph’s have had an impact on local outpatient addiction-treatment organizations. Monique Bourgeois, chief community relations officer at NUWAY, a Twin Cities-based residential and outpatient addiction-treatment service provider, said that her organization has historically had a “positive” relationship with St. Joseph’s Hospital. “We share clients,” she said, explaining that patients who have completed treatment programs at the hospital were often referred to NUWAY for stepdown care: “We’ve received referrals from all of the programs at St. Joe’s.”

But lately Bourgeois has noticed that the number of referrals from St. Joe’s, particularly from Unit 2700, has gone down. While a COVID-related decrease in patient census at the hospital may explain some of that change, she also knows that her organization continues to see strong interest from potential clients. Though Fairview was, “one of our top referents in 2019,” Bourgeois said, “our referrals from St. Joe’s in 2020 have decreased significantly, which now makes sense.”

Some of that decrease in referrals may be chalked up to operational changes, Heinz said. She explained that, in response to COVID, St. Joseph’s, along with all of Fairview, has converted many of its services to telehealth. This includes outpatient addiction treatment. The organization has also beefed up programs that offer medication assisted treatment (MAT) like suboxone, a program that was formerly available to residential patients on Unit 2700.

“We’ve opened bridge clinic services for our addiction patients that need immediate access to MAT,” Heinz said. “We’ve improved the access at our U of M Riverside campus and also on the St. Joe’s campus.”

This switch, from hospital-based to walk-in MAT treatment, could have an impact on the larger community, Bourgeois said.

“The thing with 2700 is they did some unique things for their patients. That service going away is really concerning for the individuals who are going to need that higher level of care. The unit was a great place for people to stabilize so they could move into less-intensive settings out in the community, which is really where recovery takes place.”

Bourgeois said she wonders what has happened to patients who were discharged from St. Joseph’s in March. “Where are those clients who would normally be accessing 2700?” she asked. “Where are they going for treatment? Are they showing up in other EDs? That would be a problem.”

Bourgeois said that she has heard reports from staff at East Metro Crisis Alliance that major hospitals in the community report increased ED visits from patients seeking help for alcohol and methamphetamine-related crises. This information raises concerns about the long-term health of the community, she said. “Where are clients who need these types of services going? Are they not accessing services? Are they creating even more damage in their lives?”

Substance use disorder, Bourgeois said, is a serious chronic illness that sometimes requires hospitalization for stabilization. The loss of Unit 2700 could leave some people with nowhere to turn.

“This is a chronic health condition, a chronic brain disease,” she said. “People need a place to go when they are in crisis. I’d hate to see the one place that can really help them disappear.”

“They took the worst of the worst’

The kind of care provided at Unit 2700 comes with a high price tag, Johnson said. He believes that fact may explain why Fairview appears to be looking for ways to shut down, or at least shift, the program.

For one thing, hospital-based inpatient treatment requires a higher level of staffing than other options, like partial hospitalization treatment or intensive outpatient. For hospital-based treatment, Johnson explained, “You need to have a 24-hour physician and a 24-hour nurse. Residential treatment doesn’t require a 24-hour physician, not even 24-hour nursing.”

The fact that Unit 2700 was willing to take high-risk, under- or uninsured patients made it an essential part of Minnesota’s recovery network, Pylkas said, but it also meant that the program was expensive to run.

“They took the worst of the worst. They were providing a service that was really, really complex. They took the most difficult medical detoxes. They were in a hospital: That’s how complicated the detoxes were. They were providing a high-level service and billing for a low-level service.”

Pylkas said she would bet that none of Unit 2700’s patients were covered by commercial insurance: “I’m fairly certain that they were 99 percent federal insurance.”

Reimbursements for patients with public insurance are significantly lower than for those with commercial insurance, Pylkas explained. Unit 2700 was one of the only inpatient programs in the state that accepted Medicare. Other programs like Hazelden may take on medically complex patients, but they only accept commercial insurance.

This distinction set St. Joseph’s apart, Pylkas said, but not in a good way — from a financial perspective, at least.

“For the last few years, St. Joes’ has supported this work,” she said. “When Fairview came in and took it over they realized, ‘This is a loser. Why are we doing this?’”

Because she has experience running her own addiction treatment programs, Pylkas said that as much as she felt frustrated by the news that St. Joseph’s had discharged many of their patients last month, part of her understands Fairview’s motivation.

“I don’t necessarily blame Fairview for what they are doing at St. Joe’s,” she said. “They are trying to live in the world we live in now. It’s just so cold-hearted. I get it: I think you have to be a little cold-hearted nowadays. But the closure of programs like Unit 2700 is it’s not good for the city or the state.”

Johnson said he agrees with Pylkas that the kind of care provided at St. Joseph’s is expensive —but that alone is not enough of a reason to shut Unit 2700 down.

“Hospital-based addiction treatment programs, are,” Johnson said, “expensive to run and reimbursement isn’t all that great all the time. But there is a need for that level of care. Minnesota is supposed to be the treatment capital of the world. To lose that level or care completely just seems absurd. If it’s funding, then fix the funding. Don’t close the program.”

Long history of care

The first hospital in Minnesota, St. Joseph’s was opened in 1853 by members of the Sisters of St. Joseph of Carondelet, an order of Catholic sisters who had launched the first school in the young city in 1851. When cholera began to break out among settlers and Native Americans in the community, the sisters were called to act.

Sr. Mary Kraft CSJ, retired archivist of the Sisters of St. Joseph of Carondelet’s St. Paul Province, explained that caring for members of the beloved community is a central feature of the CSJ’s work. When Bishop Joseph Cretin requested their help and offered financial support, the sisters stepped forward to build a hospital.

“We responded to that need,” Kraft said. “Our sisters at that time really didn’t have education in health care, but we cared for these very poor people suffering from cholera. In 1853, we opened St. Joseph’s Hospital in a log cabin.”

Caring for the desperately ill was a tall order, Kraft said, but the sisters rolled up their sleeves and set to work. As the hospital grew, so did the CSJs. Over the years, members set out to learn more about medicine, and many became nurses.

“Initially our sisters, with no training in health care, cared for the very poor people in St. Paul,” Kraft said. “We don’t have any type of register that indicates what people were in that cabin hospital. Our sisters became more educated in health care. We proved to be a forward-looking presence in the city of St. Paul regarding health care.”

From the beginning, Kraft said, St. Joseph’s work was focused on the needs of the poor and disadvantaged.

“As you probably know, from the beginning St. Joseph’s Hospital has emphasized providing care for the mentally ill as well as homeless people without a shelter,” Kraft said. From the beginning, the sisters supported the hospital’s programs for people with SUD; it felt like a natural extension of St. Joseph’s founding work.

While the CSJs are no longer officially tied to the hospital, Kraft said that she and her fellow sisters would like to see St. Joseph’s continue providing care for those most desperately in need of addiction treatment.

“We would like to see St. Joseph’s Hospital remain a presence in St. Paul and provide outreach to people who need us most to care for their bodies and their souls,” Kraft said. “We hope to provide spiritual care, not just physical care.”

Partner initiative paused

In February, before the pandemic hit Minnesota, Fairview issued a request for partnership (RFP), seeking “potential partners who can help transform mental health offerings in innovative ways that will both improve care and make it sustainable as a community asset.”

The RFP generated broad community response, Heinz said, explaining that Fairview held “over 100 conversations with key partners.” The initiative was paused in response to COVID-19, but she said that when quarantine orders are lifted, they plan to return to the work of figuring out how best to address the mental health needs of East Metro communities.

“We want to come around the table and identify what the needs are and figure out if we can focus on finding a sustainable solution that would not only help health care stay strong for years to come but also do our part to honor the hospital’s history — and keep and stay strong.”

Honoring St. Joseph’s history is key, Lundgren said. The hospital plays a key role in caring for members of the state’s most vulnerable communities. Though he knows what he’s heard about the unit’s closure, he tries to hold on to hope that the situation is not as dire as it seems.

“I hope what I’ve heard is wrong,” Lundgren said. “I hope the impression I’ve gotten is wrong, because I think it is irresponsible to not have any SUD beds in any hospital anywhere in the state, especially for pregnant women with OUD. Talk about somebody who’s in need of intense medical care sufficient enough to warrant admission to a hospital. I don’t understand it. I’m frightened for them: It’s not like the need is gone.”