Category: national psychiatric bed shortage

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.”


 

NH Governor Issues Urgent Call for More State Hospital Beds

As what I feel and predict will go from a quiet common state governmental call to action to hard pressed and at times, downright stingy state legislators, Gov. Sununu of New Hampshire has gone quite public in his urgent call for the establishment of inpatient acute state hospital psychiatric beds. This might seem like not so big a deal but I expect that this will become more and more frequent as the acuity of the public deficit in the capabilities to the now overflowing needs in many states overwhelmed by the numbers of chronically mentally ill.

In an article published of all places in the New Hampshire newspaper, The Portland Press Herald,  April 21,2017 entitled “New Hampshire Gov. Chris Sununu calls for more beds at psychiatric hospital,” the Governor publicly declared again but more emphatically the need for major figures in the state government agencies, especially the Dept. of Health and Human Services to mount a rapid effort with short-term corrections, which I guess  means “more beds please,” and a long-term realistic plan to address the mental health crises for treatment service delivery in the state. I think that this is noteworthy because it represents a growing trend that has finally burst into the open. However reluctant many governors have been in confronting this issue, I think that more will come out of their legislative closets and start trumpeting the needs for such actions. It has already started in such states as Texas and especially Washington state where Gov. Jay Inslee has been focusing on acute state public mental health issues as much or than any other state chief executive except the Governor and the Virginia’s two year old oversight committee on mental health issues with some of the most comprehensive and innovative programs in the country except perhaps my own state of North Carolina which has worked on these issues very quietly (in spite of HB2 ‘bathroom law’ distraction.

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State Hospital Psychiatric National Bed Count Hits Historic Lows: Good or Bad?

A now slightly dated article published July 4, 2016 in many papers authored by Lateshia Beachum of the Washington Post that I came across in the Walla Walla Union Bulletin of Washington state recorded the magnitude of the cut backs nationally in public state hospital beds psychiatric beds. While this has long been known as a trend occurring over at least the last five decades, this article startled even this observer by how many beds have been cut by state governments in just the last several years. The article was entitled, “Psychiatric bed count hits record low in state hospitals.”

The first sentence of the article hints at two of the main themes: “The number of psychiatric beds in state hospital has dropped to a historic lows, and nearly half of the beds that are available are filled with patient from the criminal justice system.”

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Good News for New Hampshire, Not So Good News for Vermont

This writer keeps monitoring for positive developments in the realm of mental health reform and there are more than a few beginning to materialize around the country.

Of brief note is the fact that yesterday, Congress began finally to take positive legislative forward movement on Representative Tim Murphy’s “MHealth Care for Families…” bill to move it toward the Senate and the President’s signature. It is a huge step in the right direction.

Another positive development of note is that New Hampshire, according to a news report by KSL.com, “State hospital opens 10-bed mental health crisis unit,” on its online site for the states’ KSL TV channel, of July 5, 2016, reported that “A new 10-bed mental health crisis unit is open at New Hampshire Hospital after almost a delay of years.” The unit opened in Concord NH but illustrated immediately the enormity of the need in “little ol’ New Hampshire,” as we might say here in the South. On the day after it was opened it already had a waiting list of 23 people for emergency admission.

The article also mentions quite significantly that this entire effort was prompted by the state’s need to comply with a federal lawsuit over these very issues that had been initiated in 2013.

This observer sadly notes that even noble catch-up efforts in the nation’s and states’ mental health reform effort that are need, all good, and well intentioned, often are behind even when they get started but at least we are finally going in the right direction in places now.

But in the neighboring state of Vermont, things are not good. For months there has been well-deserved focus on something one does not hear much about anymore, since President Reagan broke the air controllers’ strike in the 1980’s and the decline of “organized labor” and “unions’ began in this country. Another striking feature of this situation has been that this new labor against management movement has involved healthcare professionals and mental healthcare professionals, which is truly almost totally anState opens new mental health crisis unit unheard of this country. This story has been a gathering storm since last year. It seemed to start in this writer’s mind a few years ago when whichever torrential “Nor’easter” storm savaged its way up the East Coast and into inland New England which is a bit of a rarity. That storm wiped out the state’s only public mental health hospital. Vermont has been limping along borrowing/leasing psychiatric inpatient beds in the state’s small private psychiatric inpatient hospital world. The state has relied most heavily on the Dartmouth Medical School’s inpatient psychiatric services for temporary relief.

This seemed at the time the best solution that could be had on a sort of moment’s notice state of urgency and emergency. But there was trouble in paradise so to speak. Labor problems began within months and built to the point where psychiatric nurses and psychiatrists themselves were fed up with working conditions which I am not privy to at all and began to voice their concerns at the state political level. Apparently, not much was responded to and too little positive corrective action appeared.

So they began to talk of work stoppages, strikes and other things that this writer associated with the United Mine Workers’ and United Steelworkers’ and Teamsters’ unions of the 1960’s and 1970’s that were every few years regular events. It was like Yogi Berra summarized in his most famous quote, “Deja vue all over again.” I personally know of psychiatrists through indirect sources that the psychiatrists were not just posturing to wangle higher wages, but were so serious that they were actively looking for jobs elsewhere, so strongly did the group of them feel about the deficiencies of patient care and availability. And Dartmouth and the State were caught in the middle I suppose, trying to generous and even-handed about all this.

This is yet another symptom of how bitter and unfortunately rancorous the processs of advocating for change can be anywhere, in any system, when the vehicle being ‘recalled and repaired and retooled’ can be at present when we attempt both short term and long term fixes that neither come easily nor rapidly enough. Again this writer will follow this story closely. I for one have never been on strike, though I went through them as a child decades ago as both my parents worked in the mining industry and this a regular every so many years event. And in the spirit of transparency, I know I could not do this and abandon my own patients.

 

 

 

A Good Idea from a Texas Mental Health Leader

Texas, like many states, has been struggling for the better part of the last two decades with its public mental health system’s needs. Like almost all other states in the United States, it has seen its share of declining state funding for state-wide mental health services. Ageing state hospitals for the acutely mentally ill, chronically mentally ill and developmentally disabled have been closed or downsized. Short-falls have gradually appeared in the provision of outpatient services recommended and hoped for, to supplement or replace those reduced state hospital beds.

Texas for a number of years has begun to experience the enormous increase in jail populations of the mentally ill, mirroring many other states, especially New York with its travails at Rikers Island, perhaps the country’s most famous metropolitan jail facility, serving New York City. Rikers Island has lamentably been in the tragedy borne headlines in the last few years with repeated suicides of mentally ill inmates, and lawsuits by families and repeated efforts at reform and improvement, recently occurring again by necessity under the mayoralty of Bill DeBlasio.

Harris County Jail, of Houston Texas, has become known as one of the largest “psychiatric” facilities in the country. Several years ago I recall that the Harris County Jail had to increase its psychiatrist staff roster from three psychiatrists to fifteen and add a number of psychiatric physician extenders and other staff to serve the needs of this swelling psychiatric segment of the inmate population. What happened in Harris County, encompassing metropolitan Houston, was not unique to the country’s correctional systems at all, but became known readily nationwide as one of the first such settings recognized for this tell-tale barometer of the deficiencies in any area’s public mental health service system. Harris County, on a personal note, is known quite well to me, as that extended area was where my father came from and is where I have my only sibling living all our adult lives.

A very recent article online written by Stephen M. Glazier, one of the nation’s leading mental health care executives and head of UTHealth Harris County Psychiatric Center of Houston, outlined one of the best-written definitions of the concept of psychiatric “continuum of care,” that I have ever read. His article appearing at TribTalk.org, “Bridging the Mental Health Treatment Gap,” on May 9, 2016,  provided insight into Texas’ progressive efforts in just the last 1-2 years on improving the state’s mental health reform and care delivery efforts which have not received the recognition they deserve.

Mr. Glazier pointed out the common issue seen in many states who have had to face the need to close or replace aging state hospitals, and the multifaceted dilemmas of what to replace them with. He eloquently wrote of the concept of providing what he termed the middle range of less intensive residential and non-hospital based psychiatric services in the overall continuum from hospital to home or ultimate living placement for the mentally ill person. He delineated some key concepts and facts: 1) that Texas’ state psychiatric bed ratio has declined since 2001 from 13.4 beds per 100,000 persons to 10.9; and that, 2) even if Texas had ‘kept up’ with the growing mental health needs, the rapid growth population growth in the state of Texas, which has always been in the top five states in the US, the state’s level of services would still have fallen behind previous levels of beds per 100,000 population.

His idea is not a new one, that increased and nuanced provision of these middle ground “residential,” transitional psychiatric services, would to at least some degree, not only replace some state hospital beds, but reduce the spill-over, or “trans-institutionalizations,” (the new buzzword) that we are seeing as ever more rapidly increasing numbers of the seriously mentally ill, shift from non-existent state psychiatric hospital beds to jails, hospital ERs, and the streets and shelters, all never intended to serve this population. But Mr. Glazier’s description of what is needed in filling in the gaps in the continuum of care of the mentally ill is well worth reading.

 

Kids are Still Stuck in ERs for Psych Beds

I apologize for this dated article and reference, but it reminds us all again of a problem linked to the overall policy and planning malfeaseance committed by mental health planners, bureaucrats, policty wonks, legistlators from the state to federal levels, in pursuing the idiotic policy of closure of psychiatric inpatient treatment beds and resources in the publich AND private areans. That error, is of course, one of the triads of haunting reminders of our big “boo-boo” of turning mentally ill out of treatment facilities too early, not having beds for them and not providing even a fraction of the known needed “community based resources,” and that is patients stuck in ERs around the country for days. This article came from the online edition of WXYZ News of Detroit MI, a state that was one of the earlies states to undertake “mental health reforom” under then Gov. John Engler in the decade of the 1990’s. This aticle was published in June, 2015 and showed that nearly 15 years after the start of mental health refrom in Michigan, children  were STILL waiting indeterminate periods of time for a child psychiatric bed to open up for their needed attention. In crisis, mentally ill boys and girls are waiting days for a hospital bed.

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Research Shows NC Still Needs More State Hospital Beds

On December 12, 2015 the newspaper, the major newspapers in North Caroline, Winston-Salem Journal p, The Durham Morning Herald, and the Raleigh News and Observer, all published as article,Researchers measure NC psychiatric bed shortage.” In this article, hard data confirmed what has been known for a number of years, the North Carolina, in spite of its unique and laudatory efforts, almost head and shoulders above most states in the US, still needs many more psychiatric beds. North Carolina is unique and to be regarded positively in its almost singular effort to spend hundreds of millions of dollars upgradings its entire state hospital physical plants over the last several years. Almost no other state in the Union is doing this in this time of tight state fiscal budgets, and the lingering slow recovery of the now nearly 10 years banking and housing bubble scandal-induced Great Recession. NC has closed one old hospital, the former John Umsted state hospital in the “institutional” town of Butner NC, just 20 miles or so NE of Durham and replaced it and the now closed famous Dorothea Dix Hospital of Raleigh named after the 19th century’s more famous mental health reformer, Dorothea Dix, with a new nearly 400 bed state hospital , Central Regional Hospital. NC has also nearly finished completing replacing the old “Cherry State Hospital,” in Goldsboro serving the eastern third of the state with another completely new facility.

As an historical and “tourist guide” type aside, the town of Butner is tiny and sprang up in the rattlesnake-infested pine forests north of Durham in WWII when Camp Butner was built by the Army as a major military training center and was the site of a 4000 bed Army hospital for wounded veterans from the ongoing War in Europe. It was the second largest such hospital during WWII on the East Coast. After the war, in 1947, the year I was born it was sold to NC for $1 on the condition it be utilized as a state hospital for the mentally ill. On a persona note, my own training psychoanalyst, who came to NC to help state psychiatry at UNC Medical School, was named its first psychiatric superintendent. Butner is currently also the 30 year site for the famous or infamous “Federal Correctional Facity” where some of the worst federal psychiatrically insane criminals have been housed and evaluated such as Ted Kazsinski, The “Unibombers,” Mark Chapman, John Hinkley and many others.

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