August 19th, 2016

Mass. DMH releases fresh air regulations

All psychiatric patients in Massachusetts hospitals and residential programs are entitled to “reasonable daily access to the outdoors,” according to new regulations the Massachusetts Department of Mental Health issued July 1.

The regulations clarify the so-called “Fresh Air” law enacted in January 2015. The law added a sixth “Fundamental Right” to five adopted in 1998 outlining a patient’s right to make phone calls, send and receive mail, receive visitors, enjoy privacy and humane living quarters and have contact with attorneys, clergy, physicians, psychologists or social workers if desired.

Daily fresh air access depends on weather conditions and each patient’s clinical condition and safety as determined by treating clinicians, the regulations state. But it also depends on the “ability of the facility to safely provide access.”

That last caveat poses a problem for an estimated 15 to 20 of the state’s 59 hospitals that provide inpatient psychiatric care, said David Matteodo, executive director of the Massachusetts Association of Behavioral Health Systems, Inc.

“We support fresh air certainly for our patients if we can safely provide the grounds for that and if it’s clinically appropriate, and that was in the law,” Matteodo said.

“By and large for many of the hospitals, it’s not an issue because they already provide access to fresh air if they can. Some hospitals are going to have problems because they don’t have the grounds and the campus to do it.”

Treatment facilities that cannot provide patients safe, secure outdoor access must submit documentation to DMH explaining why and a remedial action plan. Facilities that cannot reasonably overcome the problem can petition DMH for a
waiver.

Massachusetts General Hospital in downtown Boston will be seeking a waiver, said Jeffrey Huffman, M.D., director of the Cardiac Psychiatry Research Program in the Division of Psychiatry and Medicine.

“The geographic location of MGH (with minimal access to green space and high traffic thoroughfares surrounding the hospital’s campus) makes it challenging to ensure patient safety,” Huffman wrote in an email.

“We will continue to work to offer off-unit excursions for patients within our psychiatric unit when possible (especially for those with more prolonged stays). Given that these patient excursions may occur less frequently here at the MGH due to high-traffic areas – as opposed to patients on units in more rural/suburban medical settings – we have worked hard to develop alternative programs to enhance our patient’s experience, including exercise rooms, rooms with natural light, music/pet therapy, yoga and gaming consoles such as the Wii.”

Matteodo said the regulations are more detailed with stronger language than anticipated. They may spur hospitals to seek approval for capital expenditures to create or improve their outdoor areas, but that will take time, Matteodo said.

“Hospitals, especially for mental health, are underfunded and financially stressed. So we’re concerned if they push the hospitals too hard to develop these plans to implement it, that could be problematic,” Matteodo added.

Advocates also have concerns.

Jonathan Dosick, a Spencer resident and peer specialist for a mental health agency who led an 11-year fight for the fresh air law, said he is disappointed by the regulations. He said there were no penalties for not providing access and no language demanding that hospitals comply. The waivers hospitals can apply for essentially allow them to get away with violating the spirit of the law, he said.

“When you look at the regs, there are so many layers of bureaucracy and factors that can be considered in the decision to provide fresh air to individuals and all patients in a unit,” Dosick wrote in an email. “The net effect can only be that many hundreds of people will be denied access.”

Outdoor access can be limited based on a patient’s clinical condition, a highly subjective factor, Dosick said. Other considerations are acuity of symptoms, elopement risk, pending legal charges or bail status, and additional supervision required.

“By no means do I believe that people who truly pose a serious risk of immediate harm to themselves or others, which could make going outside a danger, shouldn’t be able to be temporarily prevented if absolutely necessary,” Dosick said.

“But the truth is that accessing the outdoors can in itself prevent harm and agitation – especially as a form of ‘de-escalation’ during crises. Also, hospitals can create enclosed outdoor spaces, which would create no more opportunities for ‘harm’ than an interior room.”

Cambridge Health Alliance’s Cambridge Hospital in Cambridge and Whidden Hospital in Everett, with a total of 89 psychiatric beds between them, have provided outdoor access for years.

Cambridge Hospital has an enclosed outdoor patio area and basketball court while Whidden Hospital has an enclosed rooftop deck with “the best view of Boston,” said Director of Quality Meischa Gasek LMHC.

“For us it’s not much of a change in what we were doing before,” said Edgardo Trejo, M.D., interim chief of psychiatry, noting that the hospitals’ handbooks were updated to include fresh air policy language because of the regulations.

Gasek and Trejo said they were among the providers who gave feedback when DMH solicited input on a draft of the fresh air regulations. Both said they were happy with the final policy.

“Feeling the sun and the fresh air and all of those things are things we take for granted, but if you have to be on a hospital unit for a week, it’s really restorative to be able to get out in it,” Gasek said.

By Janine Weisman

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