Across 37th Street from the main campus of Cleveland Clinic Indian River Hospital, almost 2,000 patients are admitted each year to a facility most Vero Beach residents are likely to never see from the inside. This is the Behaviorial Health Center, a place of last resort for the county’s most depressed or even suicidal people, for those who have stopped taking their psychiatric medications or need to start them, for those whose world seems temporarily terrifying. Inside the walls of the pentagon-shaped building, patients find a quiet zone to ride out the worst moments of their lives. They find someone compassionate to talk to in one of Cleveland Clinic’s three on-site psychiatrists, plus dozens of trained therapists, nurses, physicians’ assistants and psychiatric care specialists. The average length of hospitalization here is 3.4 days. While that may not seem like very long, with the right care, lives can be saved, futures turned around, hearts healed and families held together through a crisis. This kind of inpatient care is not profitable, and it doesn’t come cheap, but all the services are offered to everyone in the community – the insured, the uninsured, those on Medicare and Medicaid. Last year, 1,303 of the 1,859 inpatients were involuntarily committed in accordance with Florida’s Baker Act. More than 500 people last year went voluntarily into the BHC’s care, realizing their lives were out of control and that they needed help. This year Cleveland Clinic is slated to lose nearly $3 million due to charity care provided at the Behavioral Health Center, and management projects at least $15 million in cumulative losses for behavioral health by 2029 at the current level of inpatient and outpatient care. The facility was built for the safety of patients and staff alike, designed to offer a healing atmosphere and even some comforts of home. Safe, frameless colorful paintings bolted to the walls provide some color and culture. There’s a dining hall, quiet room, recreation courtyard and a gymnasium. The gym gets used twice a day for free exercise time and pick-up ball games, but also for organized activities like yoga classes, movie nights and karaoke to add a little joy and normalcy to the lives of patients and staff. From retro molded plastic furniture that’s free of sharp edges to the barricade-proof doorknobs (which cost $1,000 each) every detail must meet special building codes and Florida Agency for Healthcare Administration specs for behavioral health facilities. Adults and children are kept separate in the BHC, with 12 pediatric beds and 34 adult beds on opposite sides of the building with locked doors in between. As the BHC presents specific challenges to both workplace safety and patient safety, hospital security staff are actively involved in tweaking operations to prevent, and respond to incidents like the one in late February when a nurse was punched by a patient admitted under the Baker Act. The mix of clientele at the Behavioral Health Center is starkly different from the main hospital, where roughly 70 percent of patients seen are seniors covered by Medicare, 1/10th are on Medicaid, and most of the rest have private insurance benefits through employers or the healthcare marketplace. At the BHC, one-third of the patients who are admitted, or enrolled in outpatient therapy cannot pay. “On any given day, we could have from 30 to 50 percent of our patients who are uninsured right here at the Behavioral Health Center. Without our community support, it’s going to be challenging to continue to be able to manage that population,” said BHC Administrative Director Cecelia Stalnaker-Cauwenbergs, who has been with Cleveland Clinic for four years. Patients who end up at the BHC arrive through the hospital’s emergency room, sometimes in the custody of law enforcement after a cry for help. The Indian River County Hospital District this year is contributing $414,000 toward a crisis care team which is on hand around the clock in the Emergency Department. Having dedicated psychiatric staff in the Emergency Department at all times helps free up ED beds and get patients evaluated, medically cleared and admitted to the BHC sooner. After the program was implemented in October 2022, the lag time between a potential psych patient arriving in the ED and getting a bed across the street at Behavioral Health reduced from five hours to only two hours, according to Stalnaker-Cauwenbergs. All of the BHC staff we met on our tour of the facility were upbeat and encouraging, and that’s a good thing since depression is the top diagnosis for patients admitted to the BHC. A full 46 percent of Vero’s behavioral health patients suffer from depressive disorders, followed by 21 percent diagnosed with schizophrenia and other psychotic disorders, 19 percent with bipolar and related disorders, 3 percent with anxiety disorders, 3 percent with disruptive and impulse-control disorders, 2 percent with trauma and stress-related disorders. Substance abuse disorders make up less than 1 percent of the caseload seen at the BHC. Cleveland Clinic Indian River Hospital Vice President and Chief Medical Officer Dr. Richard Rothman said having the ability to treat patients with depression at the hospital in conjunction with his Neurology staff has produced some promising outcomes. “In the geriatric population, many of those patients with advanced depression fail medications and they require things like electroconvulsive therapy to be able to reverse their depression, with pretty high rates of success today. We have a program on the hospital side for electroconvulsive therapy in our operating rooms,” Rothman said. “In here they treat a fair number of depressed patients, as well as patients with advanced dementia that are combative and have began to suffer from symptoms of psychosis related to their cognitive impairment,” Rothman said. Two emerging concerns in Vero Beach creating an increased need for mental health services are elderly dementia patients and autistic children. As the elderly are priced-out of skilled nursing and memory care, trying to live on their own or with family members, their bad days can land them in the Emergency Department. “There’s really no other place for them to go,” Stalnaker-Cauwenbergs said. Same with children on the autism spectrum. “There are minimal resources for parents with kids with autism. Kids with autism, may be aggressive, acting out and difficult to manage and so parents are frustrated and they get to a point where the patient ends up in the Emergency Department,” she said. Fortunately, the BHC staff is trained to care for both types of patients, to get them stable and help set them up with ongoing treatment. Last year the BHC facilitated 803 group therapy sessions and 578 individual sessions on an outpatient basis. “Just the fact that there’s a Behavioral Health Center in this community, a lot of Florida communities have to travel two, three counties over to get this type of service,” Stalnaker-Cauwenbergs said. Before they are discharged, patients are set on an outpatient treatment plan, which would be pretty intensive care of three hours per day, three days per week, tapering off to an hour a week or even a check-in once per month. Through the Intensive Outpatient Program, the staff has been able to drastically reduce the number of patients who return to the Emergency Department or become repeat inpatients. “We started with middle-school aged children, and it was a three-tier process. So the first year we were focusing on middle school, and the next year was going to be high school, but what we ended up doing because of the demand was in our second year we expanded to adults and this past year we added the high school track,” Stalnaker-Cauwenbergs said. “When you’re putting kids together, you’ve got a 10-year-old and a 17-year-old and then they're at different levels, both emotionally and psychologically so we have those three tracks,” she said. In the Covid era, she said, anxiety disorders in kids skyrocketed, as did self-injury and threats of suicide in school-age kids. “They hadn't been out interacting like they were at home. They were isolated and you know, some even had difficulty holding conversations,” she said. “Many were at home alone they had no support services, so they didn't know how to regulate their emotions.” The Vero staff modeled the program after a successful one at Cleveland Clinic’s Children’s Hospital in Ohio. The Indian River County Hospital District helped expand Cleveland Clinic’s intensive outpatient program, with funding ramping up from $200,000 in 2021-22 to $372,000 this year. Behavioral health is not the obvious place private donors and foundations donors look when they want to give money through Cleveland Clinic’s philanthropy programs, but fortunately John’s Island residents Nancy and Ron Rosner pledged $10 million in memory of their grandson Evan in March 2022. Though some of that money has been used to purchase needed high-tech equipment for the main hospital, much of the gift has enhanced the BHC and the Behavioral Health Zone in Indian River Hospital’s Emergency Department. <em>Photos by Joshua Kodis</em> [gallery ids="216743,216744,216745,216746,216747,216748,216749,216750,216751"]