Tuesday, January 22, 2008

Caring for the mentally ill: at what cost?

I was going to blog about something really interesting when I got home until I walked in the door to see piles of hairballs and even clear stuff with a pink tint. Hazel's been honking up hairballs most of her life, as she's brush- and petting-avoidant, but it seems to have gotten worse after we started giving her Laxatone, which is supposed to help with said honking. She's going to the vet tomorrow after I get done with the bullshit and ballyhoo of MHRC. At the very least, it gives me an excuse to get out of there by a certain time.

However, let me see if I can make a coherent blog today on something that isn't me bitching directly about my life or work.

WAD reader Xtine (not Charlotte) sent me a link to the News & Observer (a newspaper serving Raleigh, Durham, Cary, and Chapel Hill, NC) about the state closing two mental health hospitals. I included the link she sent me here, but I can't get it to work anymore. In the Dec 7, 2007 paper, the following article was written:

Some legislators say they want to delay the planned closing of two state hospitals, including Dorothea Dix in Raleigh.
The state Department of Health and Human Services wants to move patients from Dix and John Umstead hospitals into new Central Regional Hospital in Butner in February.

Legislators said the department was moving too fast and questioned whether there would be room for people needing help. Mike Moseley, director of the state mental health division, told legislators that the state planned to keep a 36-bed "overflow" unit at Dix that would be open to patients from the region, in addition to 24 beds for patients from Wake County.

Even if the department finds space for patients in hospitals, overflow units and state alcohol treatment centers, it doesn't mean there are enough people working in those places to properly care for them, said Rep. Jennifer Weiss, a Cary Democrat.
"You can have physical beds," she said. "That doesn't mean you can take care of people."

Good point. Psychiatric patients--both those with mental illnesses and those suffering from alcohol and/or drug problems need completely different treatment from those in a regular med/surg hospital. And even then, psychiatric disorders require different treatment than chemical dependency issues.

In the January 4, 2008 issue of the paper, the director of the NC Dept. of Health and Human Resources called for real reform in their mental health system, which is described as so in an editorial:
When Dempsey Benton, the state secretary of health and human services, called the news conference to announce his plan for "fixing" the state's mental health system, I couldn't help but roll my eyes.
I wasn't the only skeptic.
Before Benton had collected his notes and left the DHHS conference room, family members of the mentally ill began raising concerns:
"The closing of Dorothea Dix [hospital in Raleigh] should be delayed indefinitely, not just for 60 days. ... The legislature needs to be involved. ... The system needs more funding."
I don't blame family members for being wary. I don't blame them for being fed up. They're the ones who have been dealing with the fallout of mental health reform for the past several years.

Xtine asked if my company, Design Associates (known in this blog as DA), did a lot of mental hospitals. The short answer is no. The more precise answer is, not for lack of trying. We did a behavioral center floor for a hospital in Kansas, but we only did the construction documents for it--another firm that specialized in mental health design did the schematic design and design development. I learned a fair amount about designing for the mentally ill then and couldn't wait to apply it.

Later, we got (or so we thought) a commission to do an inpatient and outpatient mental health facility in Idaho. My boss selected me to do the project, and I got so excited that I started a blog. Alas, it's nearly been a year since I started this damn thing and that project fell off the face of the planet. Oh well.

The reason that not just DA, but very few firms at all, do mental hospitals is that it's hard to get funding for them. It's hard to get funding for them because it's hard to get insurance companies to pay for the treatment. It's hard to get insurance companies to pay for the treatment because results are hard to quantify. See, if you have a tumor and I send the insurance company a CT scan or MRI shot of your tumor and recommend X treatment, they'll give me the funds to treat you with a round of X treatment. At the end of the round, I send them another picture and say, "See, the tumor was 5 cm in diameter, but now with one round of X treatment it's at 2.5 cm. With another round of X, it'll go away." So, then (hopefully) they give me some more dough to finish your treatment. Sadly, psychiatric evaluations are harder to do. I mean, you can say things like "She's threatening to kill herself and everyone she works with because they picked the radiology equipment vendor that she doesn't like; we need to give her X amount of lithium to control the delusions," and the insurance company says, "Okay, but just enough for a week, and then she's outta that hopsital," because things like suicidal intent or hearing voices or can't-even-get-out-of-bed-and-can't-keep-a-job depression can't be objectively measured or quantified.

Or can it?

Here, let me plunk my magic twanger, Froggy, and quantify some shizznit for y'all. Peep this article from the May 19th 2007 Hartford Courant (as quoted on Advisory.com):

Service cuts resulting in ‘perilously inadequate’ pediatric mental health system
In Connecticut, a growing number of children with emotional problems are forced to stay overnight in EDs until appropriate treatment space becomes available, with patients spending up to two weeks in emergency beds. New Britain General Hospital’s ED treats about 30 troubled children per month, compared to 10 per month last year, and Connecticut Children’s Medical Center expects to complete 640 pediatric psychiatric evaluations this year—a 32% jump since 1998. Adding to the gridlock are patients already in inpatient psychiatric beds, who are often kept longer than necessary because there are few places in the community to send them once they’ve stabilized. At Yale-New Haven Hospital, for example, the average LOS has increased more than 70% over the past two years, from 14 days in 1998 to 24 days this year. State regulators last week called for a voluntary moratorium on additional service cuts, and a governor-appointed commission is reviewing the crisis, but hospitals and other providers are seeking to further reduce services, citing low government and private reimbursement rates...."The numbers are increasing and we don't know where to put them. That's there the [EDs] get stuck. Things come to a grind when you're dealing with children's psychiatric issues," said Dr. Steven Wolf of New Britain General.

And this from 2002 as quoted from several sources (noted internally) on Advisory.com:

Already close to capacity, EDs lose beds to psych patients
With cuts to state mental health department budgets and Medicaid forcing public and private institutions to slash inpatient psychiatric beds, mental health patients with nowhere else to go are arriving at already overburdened hospital emergency departments, often taking up ED beds for days and costing hospitals thousands of dollars. Recent stories out of South Carolina and Nevada paint a bleak picture, with psychiatric patients stranded in makeshift holding areas, regular ED patients waiting hours for treatment, and state mental health officials saying their resources are stretched to the limit.

According to the Columbia State (Freiden, 1/6/02), Palmetto Richland Memorial Hospital (PRMH) had eight psychiatric patients occupying ED beds on Jan. 4, three of whom had been there for four days, and hospital officials expected five to seven more to arrive across the next few days. The patients were awaiting placement in state psychiatric facilities, which have seen bed capacity drop by 30 percent across the past three years. The state cut $26 million from the mental health department’s budget last year alone.PRMH, which loses $2,500 to $4,000 per psychiatric patient in the ED per day, houses the patients in “Pod 7,” a room “heavy on security but light on privacy”; as beds fill in the room, additional psychiatric patients are held in a waiting room staffed by a nurse and security guard.

Other S.C. hospitals are feeling the pinch, as well: At least one of Sumter’s Tuomey Health Care System’s 27 ED beds is occupied by a psychiatric patient at any given time; non-psychiatric ED patients at Greenville Hospital System are waiting four hours for treatment because staff is overburdened caring for mental health patients; and Charleston Memorial Hospital has seen the amount of time required to place a mental health patient in a state facility increase from a few hours to a day. Although officials from the mental health department say they are working to alleviate the burden on hospital EDs—one proposal would create a 40-bed shelter on the state psychiatric hospital’s grounds for substance-abusing psychiatric patients, with operating costs covered jointly by PRMH and public funds—more budget cuts are likely on the horizon.

In the weeks leading up to Christmas—a time when mental health demands increase—Las Vegas EDs found themselves accommodating psychiatric patients for up to four days at a stretch, and hospital officials fear that stress on EDs will only increase because of a badly timed convergence of factors: the recent closure of Valley Hospital’s 11-bed inpatient psychiatric unit, increased incidence of psychiatric problems stemming from the terrorist attacks and the economic downturn, and the approach of flu season.A University Medical Center physician estimates that four psychiatric patients who recently occupied beds for four days delayed treatment for hundreds of ED patients: “That’s 360 hours [the psychiatric patients] were in there. I usually see two patients an hour. That’s 720 patients that didn’t get seen while those people took up a bed,” he told the Las Vegas Review-Journal (Babula, 12/20/01).

Although the state runs a 10-bed crisis unit for psychiatric patients requiring emergency attention, the unit alleviates only some of the burden on EDs, since patients must visit an ED for medical clearance before receiving admittance. Understaffed state facilities also contribute to the problem, since patients admitted to state hospitals often receive inadequate care and then return to EDs. The state aims to double the size of the crisis unit by spring and hopes to hire 18 psychiatrists by July to supplement the overburdened medical staff at state facilities.

So, did we learn anything, boys and girls? Like, if we don't fund mental health care, it ends up costing us in other ways, like taking nurses and doctors away from heart attacks and broken bones? Yes, that's it. See, we can quantify mental health treatment, but only in how much it costs us when we ignore it.

We lose good, valuable people to chemical dependency and mental illness all the time, like my dad and Heath Ledger. If we ignore it, it WILL bite us in the ass.


Xtine said...

My name's Christine, not Charlotte :-P

And yes, there are many of us here in Raleigh who have been shaking our heads ever since talk of closing Dix first started. In a couple of years, the local politicians are going to be scratching their heads at this sudden, unexplained increase in the homeless population (we already have enough mentally ill homeless around campus, including one called 'Trash Can Lady' with tardive dyskinesia) and non-violent offenders in jail.

I spent time at Dix as a teenager. I am dead serious when I say I wouldn't have lived to see 18 if I hadn't gone to Dix. Now I'm all sorts of successful and happy (even by other people's measure). Girls I lived with prior to Dix: I have seen one hooking, and another living in this little ghetto by campus with the city's biggest crack and gang problem, sometimes working at a fast food place near there.

...And the governor (for he is the driving force behind this - he promised mental health reform, and CLAIMS to be delivering) finds it okay to remove this effective, proven institution.

I promised you pictures - I guess I can also get you pictures showing just what PRIME real estate this campus is, including its downtown view, and verdant expanses. It's a real refuge for wildlife, too. This is ostensibly about saving the state money, but time will tell whether it's what we suspect, and some bigwig has a vested interest in this.

Mile High Pixie said...

Oh Xtine, I got your name wrong because I'm a dipshit. I even saw your name in my email when you sent me the article, and I still spaced. Derp!

And indeed, when we eliminate mental health care, we see huge increases in petty nonviolent (and occasional violent) crime and homelessness. Yet more strains on our already-beleaguered system.

ms. kitty said...

Thanks for educating a lot of people today, Pixie and Xtine. This crisis has been simmering for decades, in my experience.

Miss Kitty said...

So many people simply want to sweep the reality of the mentally ill under society's rug...and it's sad because so many seemingly "normal" people need help, people who go off the deep end "without warning," but who actually DID put up warning signs. I wish our society as a whole were more open-minded about helping the mentally ill. [sigh]

Wilderness Gina said...

I've got a t-shirt from a similar place here in GA. Yes it would be a toss up as to whether or not I'd be alive if I'd not gone to the Rubber Room in Lake Bottom. The main thing I learned is that I HAVE A CHOICE. I ALWAYS HAVE A CHOICE. What has happened to me is not the devil. It's not my ex husbands. It's not even my many cats. It's not my parents. It's ME. And I can choose to fix it or not. I no longer suffer fools.
The mess in the Carolinas has been summed up by the description "verdant and a refuge to wildlife". PUT A CONDO ON IT AND CHARGE A COOL MIL PER UNIT! YEE HAW!
Maybe what was said about South Carolina when it left the Union in 1860 is also true about N. Carolina. "Too small to be a country and too big to be an insane asylum". Maybe not. To paraphrase the Scriptures, "The Greedy thou shalt have with thee always." I has spoken. Pix, correct my spelling.