THE CRISIS IN ACCESS

Services for people with mental disabilities are in crisis. Even the crisis (emergency intervention) services are in crisis. And, the situation is worsening!

Let me start by describing what is happening to the public mental health “safety net.” First, the NeuroPsychiatric Center (NPC) opened its Psychiatric Emergency Services (PES) in October 1999 with an operating budget and staff to assess, stabilize (if clinically possible), and triage 600 patients per month to the appropriate level of care (inpatient for more involved psychiatric conditions, outpatient if the condition meets priority population, or other community care resources for all others). It is averaging over 1,000 patient visits a month.

Patients warranting the more intensive inpatient level of care, if they are on involuntary status and indigent, are transferred under court order to the Harris County Psychiatric Center (HCPC). HCPC, as the acute care inpatient partner of the MHMRA network, is funded for an average of 143 psychiatric indigent patients per day. It has been averaging right at or even above capacity in recent months resulting in, with increasing and alarming frequency, beds not being available to NPC or the Ben Taub Psychiatric Emergency Center to transfer involuntary indigent patients (as first priority), let alone voluntary admissions where a longer length of stay (LOS) appears necessary.

For the voluntary patients in crisis within the PES who need a few (3 to 5) days to stabilize their psychiatric condition, the Crisis Stabilization Unit (CSU) of NPC, on the second floor, is available. Reopened June 3 with 8 beds, it treated 53 patients in June with an average length of stay of 3.2 days per admission. Because it is already running at or near capacity, a continuing number of voluntary patients (45) had to be transferred to HCPC in June, compared with an average of 134 per month for the past six months). The CSU is expected to open an additional 8 beds during the fall.

Contributing to the growing pressures on the public emergent and acute inpatient psychiatric components is the dramatic shift that has occurred in the care provided by and through the private psychiatric hospitals. Over the past several years, in excess of 500 private psychiatric hospital beds have closed in Harris County alone. The private hospitals, you ask, how is that a significant factor? Well, the reality of these closings was primarily driven by changes in the financing of healthcare – in this case, insurance coverage for psychiatric inpatient services. Virtually, all these hospitals or hospital units (within general med-surg hospitals) provided a level of indigent care (non-reimbursed). Insiders to the private system describe how the high percentage of indigent care substantially contributed to their lack of financial viability – leading to their closing. If only 15% (which insiders say is very, very conservative) of the care provided was for persons who were indigent, the private hospitals had over 75 beds available each day in the past. Persons who used to be able to access inpatient services through the private hospitals must now increasingly turn to the public “safety net”, which has had virtually no additional Texas general revenue (GR) resources to respond to this increase. One of the contributors to HCPC’s “fullness” (lack of bed availability) has been the growing number of transfers from the private hospitals and the “walk-ins” who meet admission criteria and are admitted.

The Adult Mental Health division (AMH) is assigned a performance target through our annual fiscal year Performance Contract with TDMHMR. That target calls for 8,830 unduplicated persons who meet priority population criteria to be served each month. In June, AMH reported 9,343 unduplicated persons served. Access to the outpatient system occurs initially through approximately 700 plus intake “slots” which are available each month. The high priority patient transfers for aftercare/outpatient services occur from NPC, HCPC, Ben Taub General Hospital, the State Hospitals (primarily Rusk State Hospital), the prison system, and the Harris County jail, which averages in excess of 578 consumers per month being scheduled for care (intake). To heighten the probability that these persons will engage (follow through) with their aftercare plan (developed as a part of the discharge process), the shorter the amount of time between the scheduled aftercare (intake) appointment and their discharge, the greater the likelihood that the person will actually keep that scheduled appointment.

Unfortunately, many persons with severe mental illnesses – by the very nature of the condition – don’t recognize their psychiatric condition. With the public system as thinly stretched as it is, few resources are available to “pick up” the person at the point of discharge, support them during the transition process, and assist them in engaging in outpatient care. The “no show” rate (attended compared with scheduled appointments) is significant. When the AMH system intake process is able to accept new, call-in requests for service (calls received by the MHMRA ACCESS Center seeking services exceed 2,000 per month, over 1,000 per month seeking AMH services) the length of time between discharge to intake appointment starts to expand and further compromises the “connect” rate. To address the 578 priority transfers each month in a more timely fashion, AMH had to temporarily close access to new admissions. Now, AMH is poised to implement a waiting list for persons screened for services but unable to be scheduled into the outpatient system. Sadly, the “system” was/is having to say to people who appear to meet criteria for public coverage that, due to the capacity limitations, they must get worse, get sicker, to access care through the emergency and inpatient components. The more people access services through the most intensive and expensive components, the greater the pressure and “backing up” of the system. Does anybody understand the logic in telling people who are recognizing that they may have a psychiatric condition – have an awareness and willingness to obtain assistance – that they can’t access care until their condition worsens because the capacity simply can’t absorb additional people in treatment? Can you imagine encouraging a person who may be evidencing the early symptoms of cardiac disease to wait until they have a heart attack and then be transported by EMS to an Emergency Center’s Intensive Care Unit?

We know early intervention works best and cost less! We have a system that is spiraling downward toward a short-term crisis and inpatient system – “recycling” people rather than “restoring” them to a functional, contributory life within the community.

We, as a state, have many significant competing demands. The pressures on our Legislators are enormous. With the level of tax dollars available, they are continuously presented with “Sophie’s Choice” – which of the “children” will be cast off? There is no way – really, no way, that the state’s “children” (the various agencies and organizations which constitute the government business operations of Texas) can be adequately and appropriately addressed. We, as a public mental health and mental retardation system, are “starving” – slowly ratcheting down to “control” the numbers in need who get into care while maintaining a reasonable level of “quality.”

Beginning this September, the pressure on the “safety net” will intensify even further. TDMHMR, for very appropriate reasons, is increasing the cost “charged” per day for care in the state hospitals to be closer to, if not at, the actual cost per day for that inpatient service. Unfortunately, the total amount of allocation to cover state hospital utilization by Harris County residents in FY 03 will remain the same. So, the same use of the state hospitals this next fiscal year (FY ’03) will cost approximately 30% more each day. And, having the same amount of funds to “pay” for that care will reduce the actual average “slot” availability per day within the state hospitals by approximately 30%. We are working with the Rusk State Hospital leadership to identify specific steps which may permit us to “stretch” these resources a little further, such as reducing lengths of stay in the hospital for certain levels or types of care. If this can be achieved, then some “new” capacity will be realized. In addition, we are working with our local public psychiatric emergency and inpatient “safety net” partners to determine if there are steps we can take locally which would also create some additional “capacity” as well. Internal to MHMRA, we are trying to achieve additional efficiencies which might “free up” some general revenue (GR) to enable us to more intensively focus on and support certain high risk frequent users of the system. Certainly, where third party health insurance is present, we may be able to address these high-risk persons through a level of “wrap around” service which could, potentially, reduce some of the recycling in and out of the public psychiatric hospital system.

However, as we face this “bleak” picture for FY ‘03, the reality says that we must take draconian steps to reduce the, what will now be, overuse of the state hospitals. (Harris County has underused its allocation within the state hospitals each year for the past decade.) Unfortunately, the one place where we are able to reduce utilization is to deny transfers from the remaining private psychiatric inpatient units in Harris County. Meaning, once an indigent patient is admitted, the private hospitals will have to continue care until the person is clinically appropriate for discharge. In the past, when an indigent patient was unable to be clinically stabilized within a private hospital unit, they may have justified and received a transfer to the state hospital. This will not be possible in the future at the same level as has been in the past. As this happens, the public “safety net” will further tighten and the crisis will sadly extend to those remaining private inpatient units – intensifying the financial pressures on them to remain viable in the future. It is not right – it shouldn’t have to happen. But, it appears it will. And, furthermore, the restrictions on transfers will also have to be applied to HCPC at the outset of the fiscal year, due to the extent of state hospital admissions during August. This will have to occur even though high priority access to the state hospital reduced resources will be for involuntary, indigent patient transfers from HCPC who need more extended hospital services, at the same time maintaining, to the degree possible, continuing access for acute involuntary admissions to the HCPC contract beds.

A recent article by Ms. Margaret Downing in the Houston Press implied that the Houston/Harris County public mental health “safety net” was sinking into third world status. As incredible as it may sound, in the richest country in the world, this is occurring – now, today. When will our constituents, their families, the concerned public say: no more – no mas? Only then will the spiral reverse itself and resources more closely approximate need. In the meanwhile, we will continue to try to get the “best fit” with the resources available – juggling within our own operations the competing demands of productivity, efficiency, effectiveness, quality, and documentation. The crisis of too many in need of services, with too few resources to adequately and appropriately address those needs, is real and will be continuing. It won’t “go away.” It may wax and wane from time to time. It most certainly should be expected to resurface – reoccur in painful ways. It falls to us to do the best we can and to keep trying to do the best with the resources available. It has not and will not be easy. I want to thank each of our staff, consumers, and family members for their understanding and assistance as we walk down this difficult road together.