Category: mental health national needs

Discharging Patients to Bleak Destinations

May 11, 2017

In today’s AJC Online publication of the Atlanta Journal-Constitution, entitled: “Deaths, delays paint grim picture of Georgia mental health reformState still discharging patients to extended-stay motels, homeless shelter” authored by Allan Judd of the AJC, a despicable, but tried and true shameful expedient method of discharging and placing discharged psychiatric patients has come to light once again. Before I identify it, I would like to cite a few of its historical predecessors that were also once ‘standard practice,’ that tried to make one segment of our long “broken mental health system” work.

Several years ago, a private psychiatric hospital in Nevada gained notoriety in the news by the discovery that for two years or so, it had been discharging chronically mentally ill patients to the ‘foreign’ territory of California. Patients would be given a starter set of clothes and belongings in a suitcase, an amount of cash money whose exact amount I can not at this moment recall, and plunked down after a short plane flight from Henderson NV I believe to the airport and streets of San Francisco as a means of “placement.” This is of course set off much moralizing, scandal, and opprobrium, corrective and punitive action was taken and the practice stopped.

Now a story emerges from Georgia that it is doing something close to that by discharging “mental patients” from its state hospitals to makeshift former motels and shelters with just a bus fare token and little else,…like follow up, a ready and waiting clinical post-discharge treatment team and program? Perhaps, perhaps not.

This also reminds me of the practice of New York approximately two decades ago, in which such patients were discharged to welfare hotels; these were abandoned, closed, bankrupted, foreclosed, gone out of business hotels from another era who could not compete anymore in the glitzy market of tony New York hotels. These places would be filled with ‘dischargees’ from prisons and psychiatric hospitals with no other suitable resources, families or homes they could turn to. New York as I recall was indeed treating these unfortunate folks with outreach mental health, public health and social work teams struggling to help keep them stable in such grim and lonely settings, but these ‘placements’ quickly became cesspools of crime and corruption as the predatory types, the criminal wolves of society learned to prey upon these defenseless persons at the first of every month when their benefits checks would arrive. [In the days before automatic electronic deposit had taken hold].

New York City Police had to deal with this and it was a nightmare and a number of deaths and tragedies brought this practice to the corrective glare of the light of investigative focus.

Those detestable practices likely had to be employed since states, as they closed aging, falling down, decrepit state hospitals without funding adequate decent housing on a massive social scale for this displaced population.

The ironic similarity to refugee camps in the Middle East sprang easily again to my mind. Any person without stable resources, a supportive surrounding community of “friends and neighbors,” an adequate income and food supply, medical care and all the ordinary trappings of a life in a familiar community that most of us take for granted, and has only as many possessions as they can carry on their heads, or in a duffel bag or black plastic garbage bag or a ‘borrowed’ grocery store cart, qualifies as a “refugee,” in my mind. In fact, to stretch this wretched analogy further, we have our own internal large population of “Syrian refugees,” in our country though we largely do not realize it on a collective national consciousness. Except the “relief” workers do, who struggle valiantly to help care for these unfortunates against truly daunting odds.

As they say in real estate, “location, location, location,” I would add the phrase “funding, funding, funding,” to this national disgrace. This sector of our nation’s life and citizens needs new “infrastructure rebuilding” as much or more so than our fabled Interstate Highway System conceived and begun during President Eisenhower’s era.

 Rather than send the reader off to the article via a hyperlink I have decided to excerpt portions of the article for the reader to read and ponder first hand:

Deaths, delays paint grim picture of Georgia mental health reform

State still discharging patients to extended-stay motels, homeless shelters

Posted: 7:31 a.m. Thursday, May 11, 2017


Mentally ill patients often left Georgia’s state psychiatric hospitals with just a bus token and directions to a homeless shelter.

For people with disabilities, these same institutions became places of permanent confinement.

This is the system that Georgia, under pressure from the federal government, pledged seven years ago to radically overhaul. But with a court-enforced deadline fast approaching, the state increasingly seems unlikely to fulfill its promises.

Georgia has less than 14 months – until June 30, 2018 – to comply with a settlement it reached with the U.S. Department of Justice in 2010. The agreement followed an investigation that concluded the state had systematically violated the rights of people with mental illness and developmental disabilities.

But the state continues to discharge patients with mental illness to places where they are unlikely to get psychiatric treatment: extended-stay motels, for instance, and even the massive Peachtree-Pine homeless shelter in midtown Atlanta. All patients with disabilities are supposed to be moved into group homes or other community-based facilities, but at the current rate of progress, the state might not meet that requirement for another 10 years.

As officials try to comply with the agreement, they also are investigating an alarming number of deaths in community-based treatment: about 350 since 2014. Those apparently include five dozen suicides.

A court-appointed monitor credits the state with making many promised improvements, especially regarding crisis intervention and other services for people with mental illness.

Still, a grim picture emerges from the monitor’s most recent report, as well as from interviews and documents reviewed by The Atlanta Journal-Constitution.

It is “absolutely essential” that the Georgia Department of Behavioral Health and Developmental Disability “act with urgency to meet its obligations,” the monitor, Elizabeth Jones, wrote in late March in a report to U.S. District Judge Charles Pannell. “Although there has been noteworthy progress in certain discrete areas of implementation, the reform efforts require additional diligent and effective actions if compliance is to be achieved within the anticipated timeframe.”

Department officials declined to be interviewed.

In a statement, the agency did not say whether it expects to meet the deadlines next year. But the department said it is moving at “a reasonable pace” to move. “Transitions are carefully and individually planned to meet the unique needs and preferences of each individual and to provide the best opportunities for success in the community.”

The agency said it welcomed the monitor’s “reflections and recommendations.”

The Justice Department began investigating Georgia’s psychiatric hospitals in 2007 after a Journal-Constitution series, “A Hidden Shame,” exposed a pattern of poor medical care, abuse, neglect and bad management that had caused dozens of unnecessary deaths.

Transforming a historically troubled mental health system has been a slower process than perhaps anyone envisioned when state and federal authorities put together a plan. Already, a judge extended the deadline for compliance once, from 2015 to 2018.

The state has spent millions of dollars and reorganized the bureaucracy that oversees the hospitals and community treatment. It also closed two state hospitals, in Rome and Thomasville. All that’s left of Central State Hospital, the notorious facility in Milledgeville that once warehoused as many as 12,000 people, is a unit for people committed through the criminal justice system.

The state complied with hundreds of provisions from the settlement agreement with ease. But several issues have proved insoluble.

For instance, despite promising to provide “supported” housing to 9,000 people with mental illness, the state has managed to find such homes for fewer than 2,500 former hospital patients, according to the monitor’s report.

Vouchers that pay for the housing have been “a game changer for the people who have gotten the housing vouchers,” said Talley Wells, who runs Atlanta Legal Aid’s disability integration project. “But the reality is we still have a long way to go to complete the settlement. The state made a commitment to 9,000 people to provide this game-changing housing.”

In past years, the state hospitals, especially Georgia Regional Hospital/Atlanta, sent scores of newly discharged patients to locations where continued treatment seemed unlikely: homeless shelters, street corners, even an abandoned van on a street in Atlanta’s West End.

But from 2016 to 2017, according to the monitor’s report, the hospitals cut discharges to homeless shelters by half. At the same time, however, the number of patients placed in extended-stay motels quadrupled.

The patients typically leave state hospitals with appointments for additional mental-health treatment; in Atlanta, it’s usually at a clinic operated by Grady Memorial Hospital. But most patients discharged to shelters and motels never show up for their appointments, the monitor found. Some return to state hospitals again and again.

The lack of housing sometimes contributes to deaths and injuries, state records show.

In November 2014, records show, a staff member at a community-based mental health center promised a client she would complete paperwork to get him a housing voucher. Almost a month passed before the staff member followed through. By then, the client was homeless – and had killed himself.

Finding appropriate places for developmentally disabled patients has been just as difficult.

Since 2010, the state has moved more than 500 disabled patients out of state hospitals. But in the year ending June 30, 2016, officials managed to transfer just 26 patients and as many as 10 times that many remain in state hospitals. (The monitor’s report listed the number as 284, while the state said it is 204.)

The state has continually struggled to find high-quality community settings, especially for patients who have complex medical needs.

As the Journal-Constitution reported last month, many patients have ended up in privately run group homes where inadequate staffing, poor training, and incessant cost-control measures have put them at risk. Between 2014 and 2016, 53 people died in Georgia under the care of just two for-profit group home operators. At least 46 of the deaths were unexpected and, according to state reports, may have been preventable.

A state panel called the Community Mortality Review Committee examines each death. Minutes from the committee’s meetings show that at least two dozen disabled people choked to death on food from 2014 to 2016. Others died from bowel obstructions, a condition that is supposed to be closely monitored.

State officials redacted most details of individual deaths. But the committee’s minutes show that in one case in 2015, for example, the staff of a group home had not been trained on what foods would be too difficult for a particular patient to swallow. The state left the resident alone during breakfast with food she couldn’t swallow, and she choked to death.

The deaths show the need for better screening and more oversight as transfers from the state hospitals continue, advocates for people with developmental disabilities said.

“This is all about making sure people have the supports they need to lead meaningful lives in their communities,” said Alison Barkoff, one of the lawyers who represented advocates during the state and federal negotiations over the settlement agreement. “It’s not just moving people for the sake of moving people.”

Barkoff said the state should either fix problems immediately, if it can, or acknowledge it will need to extend the settlement agreement past the June 2018 deadline.

But what happens if the deadline passes without the state’s full compliance is not at all clear.

Under President Barack Obama’s administration, the Justice Department aggressively pushed the state to act. At one point, federal lawyers asked a judge to hold the state in contempt of court for failing to live up to its promises. That request led to the extension of the settlement agreement.

Advocates worry that President Donald Trump’s Justice Department may show little interest in enforcing Obama-era settlements such as the one with Georgia. While career attorneys in the department’s civil rights division remain on the job, the division’s top positions, which are political appointments, are unfilled.

With the state so far from complying with the settlement agreement, the matter may come to a head next year before a federal judge.

“I can’t imagine they will have met their obligations,” said Ruby Moore, executive director of the Georgia Advocacy Office, a federally mandated agency that promotes the rights of disabled and mentally ill people. “There is just too much to be done. They’re working hard, but I don’t think they have enough time.”


 

What the New 21st Cure Mental Health Law Brings with It Locally

From the Christian Science Monitor newspaper, comes a good article, New reforms to alleviate pressure on local mental health system that lays out what the newly passed this week 21st Cures Act can bring with it at a local area and gives a hint of the tremendous expectations that will arise around this bill.

In the article, the author outlines some of the major features of the bill, but more importantly, shows how its provisions, especially in the legal arena may be expected to both furnish and require the provision of nonexistent services for the mentally ill in the justice system.

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The Simplest Mental Health Reform Blueprint

In an unassuming online article published by WDKI television of Kansas, “Mental health reform proposed in Kansas,”there is laid out a summary of the initiative(s) now stirring in Kansas that show the simplest and some of the most needed mental health reform measures needed in this country. The irony is that they are incredibly simple, intuitive and long known as needed by policy wonks in the field and providers of all types in the mental health professions.

They boil down to basically simply and (stupidly enough) restoring some of the most basic lynch pins of our system of mental health care delivery.

Those essential foundations or struts of the superstructures of local or regional mental health care delivery systems of ANY size, consists of two basic things, money (“funding” in the ever dominant bureaucratic talk) and providers. Such a non-complex concept that we are starting to circle around to and rediscover. [Read angry irony in that last sentence please].

The last 20 years have seen state legislatures  cut funding for state and local mental  health services, fight Medicaid expansion to help provide mental health insurance and thereafter access to the ‘new’ privatized’ models of MH services agencies {they used to be called “mental health centers” in each country]. In most states, the new mental health reforms were SUPPOSED to cover the uninsured but somehow they often did not because of limited funding {read “block funding”]. Block funding as a concept originated mostly under the Nixon administration and since then has been largely used by a political party of a certain flavor tp punish frowned upon governmental services, such as Planned Parenthood, National Public Radio, and other entities, you get the idea. The concept was that funding was not cut off to avoid too much blowback, but given in limited and sometimes ever shrinking amounts with the admonition to choose upon what to spend it, leaving the do-gooders in the agencies to make the cuts and make the less than kind decisions and “be the bad guys.” That way legislators could crow to their constituents that they had not increased spending and had not cut funding [the latter often untrue but who’s quibbling here, this is politics…).

The other major pillar of deconstruction of the old county-based mental health system has been the ever shrinking pool of psychiatrists, counsellors, substance abuse counsellors, psychologists, child therapists of all disciplines and especially outreach workers in the old public health system sense, the “outriders,” who visited homes and if nothing else dropped the essential daily antipsychotic doses into patients’ mouths and made sure they swallowed them. It’s called “compliance.” Training programs until the last 10 years have done nothing but stay static in numbers of graduates or shrink dramatically as my one training program did for years. Some few departments of psychiatry closed or merged such as the famous occurrence at Tufts University Dept. of Psychiatry in Boston decades ago which was essentially saved and bought out by Harvard.

Reading the article makes me realize it has taken 30 years to pummel into the heads of the so-called reformers that three simple needed measures: outpatient services including residential systems of living centers for displaced mentally ill out of destroyed or as they would say in the Peron dictatorship years in Argentina, “disappeared,” hospital beds, and increase the funding and programs for providers, in this case, psychiatric residents. Sen. Chris Murphy’s bill and Former Rep. Patrick Kennedy’s now in effect merged national mental health reform bill does the same things largely except on a national basis

Dr Harold Carmel MD of Duke Psychiatry said now over a decade ago, “it will take us 10 years to get back to where we were 10 years ago.” At least we have real starts now.

 

History of Osawatomie State Hospital in Kansas as National Metaphor

Ms. Megan Hart of the Kansas Public Radio Station KCUR and the group Heartland Health Monitor partner KHI News Service has been following and chronicling the long sad story of the Osawatomie State Hospital in Kansas for quite some time now, nearly two years or perhaps longer, that this writer has been aware. Ms. Hart’s latest article, “Osawatomie State Hospital: A Leading Light for Mental Health Care Slowly Dims.” published  July 25, 2016 documents very ably both the issues of this state hospital, its parent state, and the social vise that all too many such state hospitals more or less find themselves facing in this time of hoped for reform.This piece of American state hospital history is in many ways not unique to the fascinating and very checkered social history of the American state psychiatric hospital for public inpatient care of the seriously and chronically mentally ill.

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Mental Health Reform Legislation Coming?

After several years, much needed mental health reform legislation at the Federal level may finally be coming our way.

I must state at the outset, the gnawing sentiment that at least some of the suddenly growing and politically fashionable reason for pols to jump on this now aged, creaky bandwagon stems from the recent years of increasingly frequent mass shooting we have experienced in this country. And the growing heart-rending and hard to shout down with caustic political rhetoric often based on hysterical fears of somehow losing “our” guns rabid pushback that seems to instantly spring from the same blusterers of certain quarters because, surprise, surprise, these atrocities are committed with guns instead of Nerf toys.

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Criminal Discharges When There Is No Outpatient Infrastructure

This subject and set of events is dated, and I offer my apologies to the reader. But this offering will serve to remind what can go wrong when in the course of the mental health reform process, things can go very wrong when the health care sector succumbs to criminal insufficiencies in their immediate continuum of care system, gives in ethically to a dishonest set of circumstances, does not fight back and falls back upon devising equally criminal ways of coping and inventiveness instead of advocating at any cost for their powerless patients who are dependent upon them for everything and anything they need to start over and begin the recovery process outside life in the  hospital.

Over two years ago the Los Angles Times reported on a story that I thought I would never see again in my practicing lifetime, that of “dumping patients.” I practiced in Arizonaover 15 years ago and saw the now extinct Charter hospitals do this when a patient’s health insurances would be exhausted after a month or long stay in the free-standing hospital and then be “discharged to the street” literally and abruptly. I was witness to this process as our hosptal system having a rather compassionate approach to psychiatric care would willingly accept these unfortunate and truly traumatized persons when their desperate families brought to our admission doorsteps, those of the Camelback hospitals, once a group of psychiatric hospitals in the Phoenix and Scottsdale areas, started in the 1940’s and in the days of affordable psychiatric healthcare, a nationally recognized system for its superb quality of care. These dumped persons from  the for-profit hospitals, still suffering acute symptoms such as severe unremitting depressions, suicidal impulses or pressing urges and thoughts, would be admitted no questions asked–at a loss to the hospital and to us attendings who took them on as inpatients, not expecting to be paid at all, and saw this as part of our responsibilities and part of universe of care we should offer out of our senses of service and ethics. I saw no practitioner at the Camelback system of hospitals ever turn down such a patient or take on their care resentfully.

The process of discharge in modern inpatients psychiatric care literally begins with a day or two of admission, not so that we can hurry up the process, but so that we can get a head start in lining up the needed outpatient resources, financial support, sometimes a place to live for a homeless person, sometimes family resources for a homeless minor, but always for a “best fit” between the patient and the all important team of team of therapist and psychiatrist. Often during the patient’s inpatient “do-over,” we would have the prospective therapist and future psychiatric come to visit the patient in person to have a get-acquainted session to make sure there was a good personality fit and rapport among them all, thereby giving often these persons brutalized by the “for profit” systems genuine hope that after discharge, whenver all arrived at a consensus decision made together, there would be the help ready in place to support them, giving them genuine hope instead of another trauma.

The article I came across recently in my constantly Google searchbot curating system for developments and trends inthe massive nationwide effort at changing our mental health care delivery system for all for the better was in the Los Angeles Times, entitled “S.F. sues to recoup costs for patients ‘dumped’ by Nevada hospital,” published ‘way back” in September 10, 2013. Its dated historical time of occurrence does not make it any less timely and happens to follow up on my previous post, which documented the emerging and alleged corruption of a privatized (read also for profit but sanctioned by the state who handled over inpatient psychiatric care to a national money making hospital system, to deliver service and make profit like the experiment with privatization of state prison systems who crowed about saving money to state legislatures, and of course pocketing the difference.) Well that did not go so well in a number of instances and the practice is still be re-examined in states who went in this direction.

The LA Times article though documented simply horrendous new heights of patient care callousness in patients at hospitals in Nevada, at discharge, from the Rawson-Neal Psychiatric Hospital in Las Vegas, often by bus with no resources, not provision at all for any outpatient care or personnel to San Francisco. The investigation by the newspaper the Sacremento Bee, started small but uncovered a scam/scandal of monstrous proportions and scale. It was found that about FIFTEEN HUNDRED patients had been shipped off to cities and towns in California over the previous five years. The investigation at that time was headed up by San Francisco City Attorney Dennis Herrera.

Those days were a unique confluence of corporate greed, and the growing appearance in the 1980’s of the seeds of the crisis we now face: the national shortage of adequate outpatient resources to replace which that hospital, especially the state public psychiatric hospitals could furnish even if at times, it bordered on “institutionalization.”

The solution is obvious and in everyone’s sight and radar. Outpatient resources and its infrastructure must be constructed nationwide, and governors and the no more taxes ideology of the present day and last 0 years must confront the reality that this costs money. Period. Good luck all you politicians trapped by your ideologies that do not square with reality. You need a paradigm shift in the biggest way and it will painful for your as you have to rethink your dearly held assumptions and shibboleths.

 

 

Overall Mental Health Needs Nationally

This post will be a fact-based overview of the prevalence of mental health illness conditions and the burden nationally in the United States according to the National Alliance for the Mentally Ill and the National Institute of Mental Health on an annual basis.

I am writing this post at this point in time to also contribute to setting the stage for delving into the many complex issues that this blog will address in its future postas and tasks. These issues will range from  the staggering seeming increase in demand for mental health services all sectors of our American healthcare system, and many sectors in which we have neglected and actually delayed or even faced the necessity to institute regular and proximately closely situated competent mental health services such as school based clinics and for adults in the workplaces. Currently in the last 10 to 15 years we have had continuing bitter reminders of the needs for mental health services in the schools by the occurrence of mass shootings both by students and by adults in school schools. Prior to that in the 1980s and 1990s we had so many incidents of mass shootings by disgruntled employees of the US postal system that it became a national meme and joke to say that someone had  “gone postal.”

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