March 9, 2011

Budget cuts rip through mental health safety net in state

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State budget cutbacks have forced the closure of a little known, but pivotal program at Western State Hospital that allowed difficult psychiatric patients, including those with violent criminal histories, to continue living on its grounds after discharge.

The shuttering of that facility at the end of February followed the closure in January of another 30-bed ward inside the hospital. The cutbacks are a further sign of how state budget cuts are ripping through the mental health safety net both here and nationwide, said mental health professionals.

“We’re in serious trouble,” said Amnon Shoenfeld, Director of King County’s Mental Health, Chemical Abuse and Dependency Services Division, which sends many of its clients to Western when they need long-term psychiatric care.

The lack of beds has meant more people are being held in hospital emergency rooms while waiting out their “involuntary holds.” By law, individuals can be held for 72 hours against their will if they are deemed a danger to themselves or others. During one week last month, the county “boarded” more than 25 people in ER’s throughout King County because they’d been declared a danger to themselves or others, he said. “We had no place to put them.” Boarding means patients are held, in restraints if necessary, in hallways or other spaces until inpatient rooms become available. If their holds runs out before that happens, they are free to leave the hospital.

The most recently cut program, called PALS, or Program for Adapted Living Skills, was housed in a stand-alone “dorm-like” residence on the grounds of the state’s largest inpatient psychiatric facility. It had operated for more than two decades and housed more than two dozen former patients no one else would take because of behavioral problems, medical needs, or histories such as arson.  Of the 26 individuals living there, one is now in a shelter, and two are living in motels, awaiting benefits to kick in, said Western State Hospital spokeswoman Kris Flowers. Another five were readmitted to Western on a voluntary basis. The others were all absorbed into their already overloaded home county community health systems.

Meanwhile, a patient who had been civilly committed, and had previously threatened his community corrections officer, walked off the grounds at Western State Hospital last weekend, fueling fears among some mental health and public safety advocates. They warn closures and staffing cuts could result in the deterioration of care, potentially endangering both patients and the public.

The incident is under review and a report to the head of the state Department of Social and Health Services is expected by Wednesday. Flowers said the incident was unrelated to staffing issues facing the hospital. The cutbacks have forced the hospital to cut down on overtime and juggle staff between units.

However, Jonathan Rosenblum with the Service Employees International Union 1199, which represents about 4,000 mental health care workers in the state, said the staffs at Western and throughout the mental health community have been affected by the cutbacks. “Our members who work in state institutions are more stressed,” he said. “Members who work in the community are reporting higher case loads.”

The cutbacks at Western are the latest fallout for the mental health community from the 6.3 percent across-the-board state cuts ordered by Gov. Chris Gregoire last October to close the state budget gap.

Budget cuts here follow a national trend. According to a report by the National Alliance on Mental Illness released today (Mar 9), states have cut $1.8 billion total from their budgets for spending on children and adults living with mental illness since 2009 when the recession began. The report also found that these budget cuts have already started driving up the numbers of people with psychiatric needs who are winding up in jails, and emergency rooms, or who have lost access to medication, treatment and other support.

Washington ranks 16th in the country in the amount it spends on services for people with mental illness.

Royal Barringon (left) and Eric Barbee say mental health counseling and services have helped them turn their lives around. InvestigateWest photo
 

As a result of Washington’s emergency 6.3 percent cutback, and expected upcoming cuts in the proposed 2011-2013 budget, state spending on mental illness is expected to fall by a total of $42 million over the biennium. Of that, $7 million will come out of Western’s budget. Another $17.4 million will come out of community-based mental health programs, which in turn means services will be cut to 26,000 people, according to David Dickinson, director of the State Department of Behavioral Health and Recovery, which oversees mental health care for the state. Last year, the state served 144,000 clients through its community mental health system.

The 6.3 percent across-the-board cut has also already had a huge ripple effect at the community treatment level. In November, it forced the immediate closure of the North Sound Evaluation and Treatment Center, a 16-bed inpatient facility for psychiatric patients who have been put on 72 hour or 14-day involuntary commitment holds. That facility was in Sedro-Wooley in Skagit County.

 

The state already ranks among the lowest in the country for number of psychiatric hospital beds per capita, according to the Treatment Advocacy Center, a national nonprofit mental health advocacy organization that issued a 2008 report on the bed shortage nationwide.

The bed shortage is acute on both the admission and discharge side. Western currently has 23 patients on a wait list to get in, and 205 who have been declared ready for discharge, but have yet to be placed in community treatment because they are awaiting verification of eligibility for programs, or there is no place yet to put them, Flowers said.

Bed closures are also happening nationwide. According to the just-released NAMI report, 4,000 psychiatric beds have been eliminated or are being considered for elimination around the country and 11 state hospitals have been closed or are being considered for closure.

In King County, the cutbacks have also virtually eliminated all outpatient community-based psych services for non-Medicaid patients, which includes immigrants and others who aren’t yet sick enough or poor enough to qualify for federal aid, Shoenfeld said.

Pierce County, like other counties around the state and country, also has seen increases of people with untreated mental illness in its jails and on the street.
 
“We saw a 25 percent increase in people with mental illness in our homeless count between 2009 and 2010,” said Troy Christensen, manager of mental health and homelessness for Pierce County. Similarly, the Pierce County Jail had a 12 percent increase in requests for mental health assessments during the same time period, he said.

Medicaid funding, too, is falling. According to the NAMI report, Washington’s share of federal Medicaid dollars for mental health services will fall by $338 million next year.

The cutback in outpatient services has greatly strained the capacity of the system to provide transitional support for patients leaving inpatient care at the state hospital, or who are coming out of jail, and for providing the support necessary for less acute patients to remain functional in their communities, said Trish Blanchard, director of Sound Mental Health, which has slashed its crisis services budget by 60 percent.

The number of counseling appointments Sound Mental Health can offer to people who are in crisis dropped from 18 per week to eight, she said. “These are people who are suicidal, or seriously depressed. They are not finding their way into the mental health system because they are too decompensated or too destabilized to find their own way into care.”

Service providers say demand for both emergency and ongoing care is escalating. Sound Mental Health treated about 18,000 clients last year, up 2,000 from the year before.

When support systems get cut off, clients risk losing the gains they’ve made in treatment, which in turn can put their employment, housing, or sobriety at stake, she said. “When that happens, our emergency rooms and our jails get busier.”

Arden James, manager of the Co-Occurring Disorders Clinic, which treats patients with both substance abuse and psychiatric diagnoses, said she’s already seeing that starting to happen. “It’s really frustrating to see them take steps backward,” she said.

Royal Barrington, 52, has been getting treatment at Sound Mental Health for several years and is proud of his sobriety and the gains he’s made in his recovery. But he’s also worried about what will happen to him if his medications or counseling get cut off.

“I’m really stressed about this,” said Barrington. “It keeps me so upset.”

Eric Barbee, 41, is worried as well. In and out of jail for drug-related offenses, he credited his counseling at Sound Mental Health for helping him find a medication regimen that helped control his bipolar disorder. “That was huge for me,” he said. “Huge.” But now his appointments have been cut back even as his doctors have been trying to determine the right dosages. He’s anxious about his future.

These kinds of cutbacks put more people at risk of failing to get help in a crisis, said Shoenfeld.

Hypothetically, if a student similar to the one now accused of the Arizona shooting rampage, lived in King County and had been diagnosed with a psychiatric condition for which he’d been referred to outpatient treatment, the patient would not be able to get those services, he said. “Someone with serious symptoms, but not on Medicaid, is not able to get mental health treatment in our system.”

Mental health advocates stress that the vast majority of patients with mental illness are not violent. They also stress that treatment is effective when it’s available and can restore a patient’s ability to function well in the community.

Ironically, the state budget cutbacks come on the heels of passage of new state rules that are likely to increase the number of involuntary commitments of mentally ill individuals, which means demand for the dwindling supply of beds will become even more acute.

In 2010, the Washington Legislature passed a law that would allow county workers who make commitment decisions to take into account previous violent behavior, and the testimony of family and friends when making commitment decisions. That law was passed in the wake of a number of highly publicized murders in Washington by individuals with histories of untreated, or inadequately treated, mental illness.

The law was meant to ease barriers to commitment that required a person be in imminent danger of harming himself or others, a standard that had been criticized for making it impossible to commit some of the accused individuals just prior to their acts of violence. A new study by the Washington Institute for Public Policy, a state-funded think tank, found that the new law is likely to result in a 10 to 20 percent increase in commitments, which in turn would require an addition of up to 49 beds in short-term facilities as well as additional inpatient psychiatric beds in community and state hospitals.

Instead, the governor’s 2011-2013 budget proposes more cuts, not new beds. And that worries many in the field that things are going backward for those in need of mental health care, Dickinson said.

 Farrell Adrian, President of NAMI spell out name of org Washington said her affiliates in various counties are seeing “troubling themes.” In Pierce County, for example, attendance at a local NAMI support group for people of “all diagnoses” has seen double, and the newcomers are saying they’ve been terminated from their mental health services and have nowhere else to go.

Erosion of services at the community level frustrates those who have worked for the last decade to provide earlier intervention and support for people with mental illness, and who say it will end up costing taxpayers more in the long run.

“Whether with mental illness, or chemical dependency, it’s been shown the earlier you intervene and do preventative actions and provide resources — you’re always going to get better outcomes in the long run,” Dickinson said. “It’s certainly possible as we see diminished access to crisis stabilization, evaluation and treatment, they will start showing up in emergency rooms and jails. The costs will be absorbed somewhere else.”

Edited by Rita Hibbard

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