South Dakota Illustrates the Shortage of Psychiatrists

A recent and typical article in the South Dakota newspaper, the Argus Leader, “Psychiatrist shortage worsens court bottleneck,,” sadly but truthfully illustrates one of the worst reasons for one sector or causative reason for one aspect of the mental health crisis of delivery of services in this country in all sectors, public and private, inpatient and outpatient whether clinic or private office based. There is a tremendous shortage of shortage of psychiatrists in this country. This issue has been building for over 30 years!

It started when the ability of hospitals and training centers for many kinds of residencies in subspecialties in all aspects of training of “residents,” who are doctors in training in specialties such as family medicine, pediatrics, OB=Gyn, general surgery, psychiatry, internal medicine, and even the subspecialties such as all kinds of cardiology (interventional, electrophysiologic), pediatric surgeries (orthopedic, neurosurgical) dermatology, endocrinology, all the subspecialties in radiology etc. This obviously stupid development came about when during the Reagan administration, Congress in its misplaced attempt to do something about Medicare and Medicaid fraud, thought that training centers should be allowed to transfer (divert was pejorative condemning word that was  back then to convey some kind of behind the the scenes skullduggery in money manipulation) those revenues to help fund training programs.

Now it must be understood that ALL training programs in medical residencies are expensive. Residents have to have salaries to live on, though they have always been just enough to make ends meet especially if you have a family…and residents are NOT paid wild, glorious fantastic salaries and live the good life, driving Benz’s, Beemers and Lexus’es. They drive used cars (I sure did for years, but the truth being I do anyway as my motto became with bunches of daughters in 2 different cohorts and one later adopted son, “Never Buy Retail.” Buyin Easter shoes for all the girls annually was something we saved for after the Christmas-Hanukkah holidays and even then we shopped at place called “Discount Shoes,” which was almost a 200 drive away from our home in Durham so we could afford the Easter “pony shoes,” as I jokingly called them for the feminine horde.

Residents in training also generate very little revenue from their clinical work. In the old days (imagine old man reminiscing vocal sounds and harrumphs in the background), residents at least in surgery could be billed to insurers including Medicare and Medicaid as “assistant surgeons,” and generate some lower fees which helped. This disappeared under the new punitive regulations until residents in the surgeries and other specialties that had procedures they could charge full rates for. That circumstance would typically come legally at the end of their training when they were “chief residents,” could function autonomously and ran the lower level residents and interns’ services, scheduling, teaching, assigning patients, reviewing work-ups, approving studies, in other word, the junior attendings. In this way the essential supervision of all residents lower than the chief, was handled and parcelled out at different levels and handled as appropriate to the training of the resident, by the resident one year ahead of the next resident. It worked for deacdes since the aftermath of the “Flexner” report which occurred in 1910 or so. It catalogued the incredibly sad state of medical training then in the USA and proposed virtually the entire modern training system we have today. It was a masterful work of presience with Dr. Flexner foreseeing what would be needed to train doctors to high standards, generally how to involve modern developments not even dremaed of then and legislate firm, universal standards of training at all training centerss. For instance courses were standardized and required, and another telling example is that surgery residents started to have to keep verified surgical diaries listing all the procedures they had performed, assissted in, and observed throughout their residencies. Even now these have to be reviewed and presented at the time being considered for board certification.

In psychiatry things were different as they always were. With the exception of psychological testing, psychiatry had no expensive, bodily invasive medical or surgical procedures that could be charged for with nice high fees. Psychiatry residents in training even in wealthy settings such as Cambridge, San Francisco, Westword in LA, the tony areas of New York City bordering Central Park, Ann Arbor, Chicago, Georgetown in DC, mostly had patients who were poor, had little or no insurance, even Medicaid especially in the early days of Medicaid. And when insurers began to pay for psychiatric services, they were paid for at the discriminatory rate of half, 50%, of medical/surgical rates. And so the residents in psychiatry did not generate enough monies to pay their own expenses to their training programs, office, staff, salaries and especially the time of their superising psychiatrists. Although youger pscyhiatrists in training always had psych resident mentors above that offered peripheral supervision, formal superision was conducted by one’s supervising faculty psychiatrist. It was very expensive, given the nature of what the psych trainee did, which was an interview. The supervision onsisted of the faculty psychiatrist who followed the case as long as the trainee treated the adult, teen or child, heard all the “material,” and then taught, offering advice how to interpret, how to supportively interview, how to form all alliance, how to foster self insight, how to help the person effect and move to real points of change in their lives, how to see them through crises in their lives. And of course, all the ancillary social issues were handled and learned as well, what to do with substance abuse, dysfuntional families and marriages, deaths and losses and on and on.

The point is that training of psychiatry and psychological Ph.D. level mental health clinicians was and still is tremendouls costly. Some experts estimate that until recently with the coming monies from the former Congressman Patrick Kennedy’s and other’s reparative training fund bills for the mental health professions, that some 80% of training funds nationally disappeared.

So what happened; by the end of the 1980’s training programs closed, not many but a fair number. Most reduced staffs and residents, especially the latter by half or more. My own program reduced the number of residents by 2/3.

All the big cheese observers of the “psychiatry scene,” especially but also all the other mental health discipline began to complain, then warn, then project the coming crisis of shortage of mental health provider crisis with astounding statistics and then starting to scream from the national battlements (a la the battlements of the French Bastille in my fertile imagination). We were not replacing the measley 6,500 or so child psychiatrists we used to have TOTAL in this country by the 2000’s. Those that died or retired were lost to service and most of the time communities did not have replacements.

My own experience with this was telling. In 2006 i lost my psyhiatry partner to a terminal diagnosis of cancer in a close member of his family. He was in his mid 70’s and decided to retire, moved with his wife to be near their family. This was an unexpected and rapid necessary exit from our practice but it left me in the veritable “lurch.” Our practice was an almost half child oriented practice. At the time mental health reform in NC was a true disaster mostly because it was in the middle of its development, little was finished or formed or ready in the new outpatient service delivery structures across the state. Long term employee professional of the local county or combined several county mental health centers were told they had to re0\-apply for their positions, including the Ph.D.’s and MD’s. So what happened in our town was typical; all three lady child psychiatrists left within two months and there were no practitioners other than me for the entire country. I worked for two years trying to recruit another child psychiatrist to come to my practice. I thought the prospect of the magnitude of the immediate need would surely attract someone. I recall telling several visiting candidates, ‘Don’t worry, you’ll be full in one or two weeks. guaranteed.” They all had better offers elsewhere in the medical centers or big cities. I worked two years on Saturdays and Sundays seeing and caring for the public mental health center county kids, and finally truly “burned out,” something I thought would never, ever happen to me! I finally had to face reality and closed my practice of many years and took a salaried job, but a wonderful one working as the first psychiatrist on the Cherokee Qualla Boundary Indian Reservation, my wife’s ancestral home. It was wonderful for both of us and my wife was able to return to her childhood home and be with all her relatives especially her elders. I worked my contract and helped to find a Native American replacement psychiatrist finishing psychiatric training (there was only one in the entire country) and persuaded him to come and after nearly five years’ development work there, my work was done and I then faced my now olde rage ‘category-status’ and decided to return to my original first rotation at my training residency and become a state hospital psychiatrist and “give something back.” However, slightly selfishly this state hospital offered a full range of psychiatric residency teaching opportunities that made me “teaching self” water with great anticipation since it took residents in psych rotations from several medical schools. But it so doing I in effect contributed to the growing shortage myself of psychiatrists in the country.

So what does all this have to do with South Dakota? South Dakota has a smaller population and only one state hospital. It has had even FAR worse problems staffing their one hospital with psychiatrists and has had to close beds the last one or two years because of lack of coverage or clinicians to treat them.

But as in the rest of the country the huge new influx of “legal patients,” has swamped the hospital, doing as this near tsunami of “incompetent to proceed” to trial patients has done is almost ALL the other state hospital hospitals [including my own], taken beds always for ordinary psychiatric patients in crisis.

The result as this article typically reports patients have been stranded for days to weeks in ill equipped small community hospital ERs, waiting for an acute admission bed to ‘open up.’ This practice is so widespread in the country that it has acquired a convenient name, “psychiatric boarding,” or just plain “boarding.” In some states, advocacy organizations have sued states and their hospitals for such practices. It is a widespread problem with presently no real solutions. Most state legislatures are not willing to fund and construct the many dozens or hundreds of beds that would accommodate these legal patients so they are treated and accepted first by the admissions units of the state psychiatric hospitals who have NO choice but to do so because these patients are court ordered.

I will take the liberty and quote three paragraphs from the above referenced article to illustrate the problem as it currently bottlenecks both the inpatient psychiatric hospital’s mission and obligation to treat its patients and the legal system that must observe and uphold the constitutional right for a defendant to be able to understand and participate in a capable manner in their court proceedings and to fully cooperate with their counsel.

From the Argus Leader, “A shortage of psychiatrists in South Dakota is hampering efforts to address a bottleneck for court-ordered mental health evaluations in the state.

An Argus Leader Media investigation found mentally ill defendants were jailed for half a year or more as they waited for exams to determine whether they are competent to stand trial.

The state’s mental health hospital says it is not responsible and does not have the resources to conduct all of the exams, and that’s forced counties to seek out private psychiatrists to help manage a surge in criminal cases involving defendants with mental illnesses.

The problem is that few private practitioners in the state are qualified…”

Finally, to close out this long winded treatise on the shortage of psychiatrists, I will further take the liberty to quote the Argus Leader’s data in this article which gives startlingly information on how understaffed the entire state is with (or if you prefer from a pessimistic standpoint) without psychiatrists, the following passages will delineate the dimensions of the shortage that exists NOW:

“A Kaiser Family Foundation analysis this year found South Dakota has enough mental health professionals to meet only about 15 percent of the need for services in the state. There were an estimated 30 psychiatrists statewide in 2014, according to the U.S. Bureau of Labor Statistics.

The South Dakota Department of Labor and Regulations puts its estimate at just 20 psychiatrists statewide.

Based on BLS and Census data, South Dakota has fewer than one psychiatrist for every 30,000 people, one of the lowest ratios in the region.”

At the end of the article, the author listed the relative ratio’s of psychiatrists per 100,000 persons in 2014 that last year for which such data was fully available. These statistics are woeful as one accepted statistic commonly accepted for urban areas is ONE psychiatrist per only 3,000 people to 30,000 persons at most. The Midwest illustrates its serious shortage more than almost any area of the country. But all areas have them, except by and large cities in which there are one of more medical schools and concentrations and availability of specialty training programs.

Psychiatrists per 100,000 people, 2014

Nebraska   3.2

South Dakota  3.5

Iowa  4.8

Minnesota  6.6

Wyoming  6.8

Montana  11.7

North Dakota  Data not available

Sources: Bureau of Labor Statistics, U.S. Census Bureau

 

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Drastic Soluution to Court Ordered Psychiatric Evaluations: Stop Doing Them

In an article published this date,July 20, 2017 in the Argus Leader of Yankton South Dakota, “State hospital no longer performing court-ordered mental health exams,” and referenced articles published several months ago in the same paper which I have referenced and linked below, there is explained in some of the best and most clear, succinct reporting I have seen in several years, all the fuss and complicated issues surrounding one very critical part of the national mental health service delivery crisis for which there appears no end or easy solution in sight.

The problem is that in South Dakota specifically to start there as our study example, the state psychiatric hospital system (the state has only one such hospital because of its relatively low population) has been and is still been flooded with court ordered inmates from county jails all over the state for admission to be given forensic evaluations for fitness (competency is the legal term) to stand trial. Most of these persons are truly mentally ill, which is another part of the Gordian knot comprising this crisis that has been developing for over three decades nationwide. South Dakota’s hospital came under review and journalistic investigation by the Argus Leader some six months ago because 1) overcrowding was at a crisis level; 2) the hospital was running full and could not literally admit in a prompt and responsive manner the growing number of “ITP” patients (incompetent to proceed to trial); 3) mentally ill inmates were logjammed in unrelenting and overwhelming numbers in the state’s country jails; 4) counties’ budgets were being decimated by the costs of housing and trying to treat as much as they could with very limited resources, the psychiatric needs of these stalled patients/inmates; 5) the rights of the inmates/patients to a reasonably speedy trial-disposition of justice-were being far exceeded.

This is NOT a problem particular to way up there northern plain state of ‘lil ol’ South Dakota with its very small population, perhaps limited state revenue and budget. This is a NATIONAL CRISIS that is being seen in virtually every state in the United States. There are many factors for this and on the occasion of this post I will not go into much detail on why this has grown into the “Feed Me” monster plant of the famous play of decades ago that is devouring resources, facilities, budgets, policy wonk’s best ideas and stretching our mental health delivery system past its breaking point. The one factor I will briefly waggle my “I told you so” sorrowful finger at, is the predicted result of trans-institutionalization that I have written about quite often in this blog. ‘Nuff said for now. But it will be a very thorough conversation and historical revelation and analysis for another time.

Another very telling factor that I have not included in my list of causative/exacerbating factors above because it is literally out of South Dakota’s control, is the extreme shortage of psychiatrists and allied psychological professionals especially both forensic psychiatrists and psychologists. Training programs for these specialists have been too small since I was a resident in the 1970’s and the output of teentsy numbers of these subspecialists is now catching up with us in a big way and forming a “chokepoint” in the delivery of these systems for which there is no timely solution.

So what did poor South Dakota’s state psychiatric hospital do? They decided bravely to completely STOP performing such psychiatric forensic evaluations. This decision somewhat flabbergasted (I have loved that word since I was a blabber mouthed kid) at this really brave and somewhat bureaucratically perilous, singular decision. I think South Dakota is the only state to make such a governmental service decision. In my world, this is almost akin to stop paving the highways, or shut down half the public schools or some other state governmental function that we all take for granted whether we are aware of its importance or not.

The state went so far as the leave monies for all these legal-psychiatric services completely out of the state budget! To read the account of this very unusual move, read the following article: “ Mental health court money left out of state budget.”

Perhaps other states have done the same thing recently but honestly my Google and other search news bots have not alerted me that such has occurred at all anywhere. As we say in the South, I have not “heard tell of”  anything like this.

Were State Psychiatric Hospitals Better 100 Years Ago?

A fundamental intellectual tenet of mine is that to have a comprehensive and ‘honest with oneself’ grasp of historical and social long term processes, history of the subject being studied should be included. George Santayana’ famous quote that those who ignore history are ‘doomed’ to repeat, seems to hold more and more power of truth the older I become.

The history modern mental health care began in almshouses, shelters for the developmentally disabled and intellectually disabled, earliest perhaps by the Quakers of the early 1700’s in Pennsylvania. Theirs was an extraordinary (and still is) ethos of charity, helping those in need and one of the original origins of the philosophy of “non-violence,” embodied in conscientious objects in our wars and taking on the needs of the shunned, ‘repugnant,’ disabled persons who frightened the average person. It is no new concept that state hospitals were built intentionally out of the ‘boondocks,’ the countryside, away from towns so delicate sensibilities of citizens were not disturbed by the sight of unpredictable persons, that in reality before the era of modern treatment in the middle half of the 1900’s NO ONE really understood beyond crude empirical approaches, i.e., “we do not know how but this medicine works on hallucinations so let’s give it for that.”

There are many, many articles, books, some films from the earliest days of the then miraculous, wondrous Brownie 8 movie camera, that record the abysmal conditions of many state psychiatric hospitals in the Western world and the US, Latin America, Scandinavia, Europe and a few other regions and countries where modest efforts at housing the chronically mentally ill occurred. For instance, it is not well known that the famous country singer, Johnny Cash, established and supported an orphanage for children in Jamaica and did so very quietly as a true philanthropist.

If it were not for Google’s miraculous search bots, I would never have come across or read the article to which I wish wholeheartedly to refer the reader. It is from this week’s edition of the English newspaper, The Daily Mail. In the usual British brutal journalistic tradition it has simply ghastly title: “EXCLUSIVE: Chained to their beds with no heat or water, and left to lie in their own excrement: How the 19th century mentally ill were sent to hide away in grisly insane asylums and categorized as ‘idiots’, ‘imbeciles’ or ‘lunatics,’

This article itself is based on what appears to be a singularly striking book with lots of old pictures of life and patients in state psychiatric hospitals in Scotland and England, entitled, ” Lunatics, Imbeciles, and Idiots: A History of Insanity in Nineteenth Century Britain & Ireland, by Kathryn Burtinshaw and Dr. John Burt.

Continue reading “Were State Psychiatric Hospitals Better 100 Years Ago?”

A State Hospital’s Troubles: Typical for the Country

Western State Hospital in Lakeland WA is undergoing troubles again. In an article published on the local tv news outlet KOMO-tv, entitled,  “Western State Hospital warned again about the loss of federal funding,” by Keith Eldrige on Friday, July 7th, 2017 the details and some of the history leading up to this sad state of affairs is enumerated in straight forward and informative fashion.

A little background is in order to be fair and honest to the reader as taking thins out of context can almost always lead to a quick and wrong impression. As state hospital go, Western was doing fairly well under very trying circumstances that have been in NO way unique to it alone. It has been besieged in recent years like all state hospitals by the new wave of “ITP” or incompetent to proceed patients that have emerged in nothing short of droves of thousands across the country. These patients are one of the most obvious results of the “trans institutionalization” of patients from the ‘under-bedded’ state and local public psychiatric hospital systems nationwide through the misguided efforts to cut inpatient psychiatric beds drastically to save monies in state budgets, in turn, themselves slammed around economically by the huge impact of the Great Housing Bubble burst [read runaway Wall Street greedy foolhardy faulty and dishonest mortgage packaging of the 2000’s]. States had to cut budgets drastically and almost universally their mental health segments had to be cut and beds cut and the hospital closed out of hand in many states. So we had the well-known issue of the chronically mentally ill appearing out in the public without almost any housing and inadequate outpatient services in almost every state. And to survive they did things that put them in jail in droves. It was perhaps a little ironic or surprising that one very conservative [I do not mean that politically at all] group nationally, the associations of country sheriffs and other such law enforcement policy groups became some of the EARLIEST non-clinical groups yelling to the rooftops along with mental health advocacy groups such as NAMI, the Judge Bazelon Center, and Dr. E. Fuller Torrey’s national advocacy group, The Treatment Advocacy Center.

Dr. E. Fuller Torrey, national psychiatric advocate for the severely mentally ill
Western still had budgetary gaps and big ones. It had deficiencies in safety, inadequate fire control measures, areas of the structure that drastically  need renovation, and still staff issues. Staff have been required to work overtime on a regular basis for many months to make up for the migrating losses of staff to other facilities as detailed about. This resulted in frank and known and identified burn out and work fatigue identified by the hospital and more staff quitting. So Western has been in a vicious cycle of I suppose almost barely keeping its head above water with respect to staff and still not being able to get back up to full capacity.
The Governor of the State is Mr. Jay Inslee, a Democrat. He has a Republican-controlled state legislature. He has worked openly and tirelessly with the legislature to craft compromise funding bills to help the state hospital system and it has been hard and slow. And, in effect, not fast enough to remedy the long-standing and recent acute problems of Western State Hospital over the last two years or so.
The importance of all this is of course money. Money to support the hospital, part of which obviously comes from the state’s legislature and the rest from usually not very large patient collections, but the rest coming from the Federal agency, the CMS. If a hospital loses accreditation, it loses CMS funding. And then the state has to make up the difference immediately often to the tune of a million dollars a month or more in most states I have followed over the past decade or so that have gone through this painful process. Often the Feds, such as CMS, give extra time, in this case, another 60 days for Washington to put in place beginning remedies, in order to give the whole process time to hold off on the “death sentence” of cutting off federal funding altogether as it usually takes a long time, like well over a year or so if not more, to make big and expensive repairs in the physical plant and recruiting psychiatrists and psychologists to the tarnished hospital.
Western State Hospital and Washington are one of several state hospital systems in the same position and there are no easy answers for any of these bodies that are ‘under the gun.’ But one answer is clear and has been in plain sight for decades and is THE root cause for all this, large and continuing sums of monies must be spent by state legislatures to correct the neglect of decades of the mental health delivery systems.

Millidgeville State Hospital, History & Pictures

I had a residency classmate at my training program some 40 years ago who eventually served as medical director of this huge old state hospital. I visited it once long after he had worked there for a stint and was overwhelmed by its size and vastness of its campuses. I had never seen such a massive mental hospital facility and was not prepared for its size.

It had its share, or more than its share of scandals and periodic tales of abuse for decades and did many such state hospitals especially early in their histories before the era of modern treatment with advent of effective medications, movement beyond just ECT, or electroshock therapy for out of control mania and truly treatment resistant long-standing depressions and the addition of all the behavioral and cognitive therapy, art therapy (and that really is valuable stuff speaking as someone who in my younger stupider days, thought it was not very relevant [I was a dummy young Turk type then to some extent], music therapy, DBT [Dialictal Behavioral Therapy which is wonderful stuff], psychodrama [which is sadly not practiced in enough hospitals] and so on.

What I am leading up to in my habitual meandering style is pointing the reader(s) to a post I somehow discovered one night recently, on a sort of mixed text and wonderful pictorial history of Milledgeville State Hospital [latter called Central State Hospital in recent modern days before it closed in 2016] that is so well done I had to do this post and highlight/publicize it by offering its URL so readers could read it and marvel at this institution, its history and dilapidated kind of grandeur. I know there are those that would rankle at having the term ‘grandeur’ applied to state hospital that personally represented horrors to them or their extended families, and I understand and completely accept that sentiment as all state hospitals had their sins, tragedies, and horrors to say the least and were in ways certainly ignoble chapters in our nation’s history.

But anyway, here is the URL to the extremely well-done website that shows an enormous amount of artistic photographic effort and historical research that I think many will enjoy and as I said above, marvel at. URL: Milledgeville State Hospital in Georgia.

 

Georgia Struggles with Nationwide Problem of Housing for Chronically Mentally Ill

Finding housing for the chronically mentally ill after discharge from psychiatric inpatient services has come to be one of the most vexing problems that all states continue to struggle with. In brief, this has risen to be one of the paramount issues facing every state’s public mental health service delivery system due primarily to two factors: 1) decades of “de-institutionalization,” phasing out the practice and philosophy of housing the chronically mentally for decades or lifetimes, coupled with cutting back in every state of the numbers of state hospital psychiatric beds, and, 2) the rise of legal decisions and enforcement measures since the 1970’s emphasizing transferring patients to “less restrictive” levels of care, which is most clearly spelled out and embodied by the Olmstead Supreme Court decision.

An earlier post described the revelation that in Nevada in this past decade or less, that state had been discharging patients on planes to San Francisco, California! Patients were apparently given a suitcase of a supply of clothes and supposedly some amount of money to help them set down roots in the neighboring state. By report, this practice had been utilized for about two years before it was revealed and a brouhaha resulted. New York state’s practice of turning out of use old hotels turned into “welfare hotels,” for housing not only persons or families on welfare but also the chronically mentally ill and paroled ex-convicts has long been known.

This past week or so, an article entitled: “Deaths, delays paint grim picture of Georgia mental health reform: State still discharging patients to extended-stay motels, homeless shelters, by veteran reporter Alan Judd was published May 11, in the Atlanta Journal-Constitution newspaper. that shows the huge problems states face in completing the long heralded de-institutionalization process, that of moving the “CMI” [chronically mentally ill] populations from hospitals to safe housing with adequate outpatient treatment, supervisory and rehabilitation services.

Georgia has been contending with this issue for at least 7 years since the federal government began to monitor and require positive changes in finding housing for the discharged patients, instead of releasing them as the article put it: “with just a bus token and directions to a homeless shelter.” Now Georgia apparently faces the imposition of a looming deadline of June 30, 2018, to comply with a legal settlement and pledge Georgia entered into with the federal U. S. Department of Justice back in 2010. 

The article even-handedly notes the many steps of progress that have been undertaken and implemented by the state and gives credit for notable and partial improvements.

But this article illustrates the Herculean tasks that states face in transitioning themselves from the traditional custodial role utilizing large massive hospitals and viewing treatment as often lifelong or at least so long that it may as well be lifelong, to a system aiming at re-integrating the chronically mentally ill safe enough to be returned to the communities and constructing complete new and entirely different systems of housing and care for literally thousands of persons within spans of a relatively few years. There are no simple answers in any quarter and the task which may have been viewed as achievable within approximate task-timer periods clearly is proving to be greater, harder, more coslty and complicated than likely almost anyone could have imagined.At the least, enforcement by the “feds,” may have to consist of extending time periods of effort to the states and partnerships that help with costs and perhaps even approaches not yet widely appreciated by any of us.

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.”