The Mental Health and Mental Retardation Authority of Harris County

Early in October, Harris County dedicated the long-awaited expansion and enhancement of crisis care, emergency psychiatric services called the NeuroPsychiatric Center (NPC) of MHMRA. On the radar scope of the Mental Health Needs Council of Harris County for over two decades, the NPC embodies the hopes and dreams of many people: consumers of psychiatric care who may be seriously depressed, or highly agitated, or hearing voices telling him/her something, often disturbing, or anxious to the point he/she can hardly function; family members who experience their loved one as behaving in unusual, disturbing, at times dangerous ways; law enforcement officers who come across or are called to intervene with people in the community who are identified or suspected of being in an acute psychiatric crisis; mental health and other professionals who need an immediate response facility to evaluate and intervene with someone they are in contact with who has raised concerns as to the safety or well-being of the individual at a time where they, the care-giver, are unable to respond; and, countless others, cutting across all segments of our community. Each, in his or her own way, looked forward to the time when Harris County would have the capability to more adequately respond to psychiatric crises. The following week, NPC opened its first floor to patients, called — not surprisingly — the Crisis Center. This component, open 24 hours a day, 7 days a week, will accept both voluntary and involuntary patients for evaluation, treatment (stabilization, if possible), and triage to the appropriate level of service (acute inpatient if clinical response is not forthcoming — outpatient services, if stabilization occurs). The second floor, 39-bed short-term acute inpatient unit (3-day average length of stay) should be opening shortly.

A special thanks has to be provided to the Department of Psychiatry at Ben Taub General Hospital (BTGH) who, for all these years, have manned the only public emergency psychiatric unit of 12 beds for voluntary and involuntary patients in the County. Often overwhelmed with demand and subject to the requirements of the Texas Department of Health holding One South to no more than 12 people, the Psychiatric Emergency Unit at BTGH has often had to go on drive-by status, unable to accept any additional patients until patients were discharged or transferred. Having to turn people in crisis away has been incredibly frustrating to the Ben Taub staff. Ben Taub Psychiatric staff have been extraordinarily helpful as have the staff of Harris County Psychiatric Center (HCPC) as the MHMRA staff have been developing the policies and procedures for the opening of NPC. The BTGH Psychiatric EC unit will soon be able to more intensively focus its efforts on the niche that only it can provide within the public sector — the psychiatric emergency intervention capability for people who also have a significant, concomitant medical condition. It is essential that this capability remain intact and responsive to the community. NPC will interface with the BTGH Psychiatric EC, being responsive to requests for transfer of medically stable patients such that open capacity may be maintained and drive-by status minimized, if not eliminated.

Will NPC "fix" all of the mental health problems of Harris County? Of course not. One of the significant question marks revolves around the influx of "new" patients to NPC from law enforcement. Thanks to the efforts of the Mental Health Association of Houston/Harris County and the Mental Health Criminal Justice Task Force established by County Judge Robert Eckels, two major federal grants have been obtained to first research, then select a law enforcement intervention model for the Houston-Harris County area. Following site visits of the three nationally recognized sites, the Albuquerque model was selected and a pilot of 60 Crisis Intervention Team (CIT) officers trained within the Houston Police Department (HPD). Thanks to the second grant, the CIT program may be rolled out throughout all of HPD after the first of January, along with other major law enforcement jurisdictions that have volunteered to implement the CIT program.

CIT will enable, following 40 hours of training, the officers to better recognize persons in what may be an acute psychiatric crisis and intervene with techniques that, hopefully, avoid the use of undue force to defuse the situation. Currently, law enforcement has the choice of taking the person to the Ben Taub EC (often having to wait hours due to life-threatening conditions taking necessary precedence with the stretched staff resources), incarcerating the person in response to the behaviors being evidenced, or turning aside and not intervening if the situation does not include an infraction of the law. In fact, law enforcement is often the front line of intervention in situations involving an identified or suspected person with an acute mental illness. They should be able to respond, transporting such a person in crisis to an appropriate facility for professional evaluation and, if warranted, treatment. A person who is indigent in a psychiatric crisis should not be left to the streets or placed in jail, unless the crime clearly warrants such incarceration. NPC will provide a timely response for law enforcement in such circumstances — and the response from law enforcement to date has been wonderfully supportive. Thus, one of the question marks for all of us in the public sector, NPC, Ben Taub, HCPC is how much additional patient traffic will surface. In a county with a population larger than many states in the United States, the limited public psychiatric bed capacity may be strained to the max as NPC fulfills the role it was designed to fill.
Additionally, many of the private psychiatric and general hospitals have persons in crisis who attempt to access services but are without resources, either personal or third party, to cover such care. These persons need access to the public sector and efforts will be undertaken to develop a protocol for the transfer of appropriate emergency cases before they are admitted into treatment in the private sector. Most people in the community do not realize how much unfunded charity care is actually provided through the private hospital system, at times reaching a level which may undermine the hospital’s or unit’s fiscal viability. The interrelationship between private and public inpatient services is an important yet not well defined aspect of the overall "safety net". Over the next months, this aspect of the system will receive greater attention through private-public sector discussions. Efforts to channel appropriate patients (either indigent or with coverage) into the public sector for care that is truly the purview of the public sector will only serve to heighten the pressure on the limited public resources.

With increased flow from CIT officers, transfers from the private sector, and increased access from consumers of psychiatric service and their families, the NPC is expected to be busy, very busy. Anticipating service to well over 1,000 persons per month, the NPC budget and staffing pattern has been established for FY2000. It is important to understand that the MHMRA budget of tax-based revenues does not include sufficient resources to cover the full operating expenses of NPC. Rather, the budget has been predicated upon the assumption that a significant percentage of care provided will be to consumers who have Medicaid (approximately 40%) or Medicare (approximately 10%) or other third party coverage. To fulfill its role in the public array of intensive psychiatric services, NPC must earn a substantial part of its operating budget without diminishing the already woefully under-resourced outpatient system. Which leads to the final reality to be addressed in this article. The Adult Mental Health (AMH) Division had a new performance contract target established by TDMHMR of 8,830 unduplicated consumers to be served each month in FY2000 (an increase of approximately 25% over the performance requirement from last fiscal year). This target was established in direct response to the Legislative increase mandated in the Appropriations Bill. Let’s stop and think for a moment — would any well-meaning member of the Texas Legislature mandate an increase of 25% more highway miles to be constructed with the same budget from the previous fiscal year? Of course not — not unless the quality of construction was substantially reduced to cover the additional mileage. In essence, that’s what has happened in the public mental health system. All over the state, additional people are being required to be served, in some cases with slightly more, in some cases with the same, and in some cases with less funds than available in FY99.

One can argue that the pressure on the system is to become more clinically efficient. Or, perhaps, the system will by necessity have to carefully scrutinize persons who have received continuing services for years (the public sector really does serve persons with long-term, perhaps life-long conditions, in addition to providing acute care services) and decide whether that care may need to be modified or limited. Furthermore, the array and extent of services will be carefully reviewed in light of funding availability after medications as the mainstay of the state general revenue (indigent care) system is provided. What is clear this fiscal year, more of the public mental health outpatient system will have to serve Medicaid consumers than ever before. More revenue to maintain services will have to be earned. Fewer on-going treatment "slots" will be actually available for the indigent consumer due to funding constraints.

This is the reality at a time when increased consumers — increasing numbers of uninsured people in psychiatric crisis — will come to the attention of the public system through the opening of the NPC. Does this irony seem real to you? At a time when we are poised to have the most responsive and available public psychiatric emergency/crisis services in Harris County’s history, we will have fewer available post crisis "slots" to provide aftercare services. In the absence of appropriate aftercare outpatient services, more and more people will access the public system in crisis — and later on in crisis again — recycling into the most intensive and expensive component of the system. All aspects of the system must be adequately resourced to provide the level of services and supports necessary for persons with neurochemical disorders of the brain to more fully reach their individual potential as contributing members of our community.