Monday, November 23, 2009

People with mental illnesses in Ohio find getting state hospital care difficult

From the Dayton Daily News in Ohio:

When Gov. Ted Strickland approved the June 2008 closure of Dayton’s Twin Valley Behavioral Healthcare on Wayne Avenue, ending a 153-year history, it was with the promise that local people with severe mental illness would still have access to state hospital care, though they’d have to go to Cincinnati to get it.

In practice, that access has been curtailed as the local mental health services board, hit with major funding cutbacks, is approving far fewer state hospitalizations — only 69 admissions this fiscal year compared with 262 in 2008 and 291 in 2007.

Officials at Montgomery County’s general hospitals say that’s resulting in serious consequences. Patients aren’t getting the intensive care they need. In some cases, violently psychotic patients are being held for weeks at general hospitals ill-equipped to handle them, the cost of their care written off by the hospitals. In other cases, unstable patients are cycling through hospital emergency rooms and prematurely turned out into the community, where they might endanger themselves and others.

Dr. Douglas Songer, a medical director for psychiatry at Miami Valley Hospital, said none of his hospital’s 68 requests for admission to the nearest state mental hospital, Summit Behavioral Healthcare, were approved without repeated attempts. He believes that patients from Montgomery County have a much harder time being admitted to a state hospital than in most other areas: “It’s like a stuck door and we beg and we plead until someone opens it.”

Some psychiatrists feel the current system has broken their trust with their patients. At Good Samaritan Hospital, medical director Dr. J.J. Schulte feels ADAMHS constantly second-guesses his assessments. In the year after Twin Valley’s closing, the mental health board approved only 27 initial requests for admission to Summit, compared with 140 admissions to Twin Valley the year before.

“We cure as many people as cardiologists, yet we’re not being trusted to make these decisions,” he said. “We have the patient in front of us instead of an outside person who’s making a judgment.”

Songer and Schulte fear their psychiatric intensive care units have come to resemble miniature state hospitals, with dramatically longer stays and a higher percentage of violent patients. “Other (mental) patients are getting frightened by the severely ill or psychotic patients,” Songer observed. “They’ll say they’re better just because they want to get out of the unit.”

The problem has exposed a growing rift between groups with alphabet-soup names. The Greater Dayton Area Hospital Association (GDAHA) accuses the Alcohol, Drug Addiction and Mental Health Services Board of Montgomery County (ADAMHS) of shortchanging sick people by refusing to pay for state hospitalizations. ADAMHS is the funding conduit for mental health services, using county Human Services levy and state money. It’s required to pay for state hospitalizations, but not for stays in general hospitals.

Songer said board officials are trying to slough off their responsibilities on the hospitals: “They would like us to be a state hospital that the ADAMHS board doesn’t have to pay for.”

Joseph Szoke, the ADAMHS director, denied that, but acknowledged he’s trying to hold the line on admissions to Summit in an era of declining funds. The state cut its funding to the local ADAMHS board from $18 million to $12 million this year. “I don’t want this whole thing centering around funding and money,” he said. “It’s about how do you provide the best care for the people in the community with the resources that you have, knowing that the resources you have aren’t going to be enough?”

A failed system?

Margaret Gerken, 79, of Trotwood said the current system is failing people with severe mental illness. Her schizophrenic son set fire to their Trotwood home Sept. 4, two days after being discharged from a brief stay at Grandview Hospital. Craig “Rob” Gerken, 43, who spent time at Twin Valley years ago, is due for a court appearance Monday, Nov. 23, on a charge of aggravated arson. He has pleaded not guilty by reason of insanity. The house sustained heavy damage and several house cats died in the fire.

Dr. Gary Balster, medical director for Grandview’s psychiatric services, said he’s barred by privacy rules from commenting on the case. But, he said, “we treat people for as long as they need to be treated, through the acute phases of their illness. We would not discharge a person if we felt they were a danger to themselves or others.”

Gerken supports the controversial Morningstar project that ADAMHS has proposed as an alternative to Summit. Szoke wants to create a 16-bed adult “step-down” treatment center in Old North Dayton through Dayton’s Nova House. Morningstar would take people prescreened for transfer to state hospitals and people in state hospitals who no longer need such a high level of care. It would provide at least 30 hours a week of treatment, including therapy and medication stabilization.

“I’m not saying it’s an answer to all the problems, but, dear God, it’s a start,” Gerken said. “Somebody has to start somewhere.”

Fierce criticism

Szoke said Gerken’s experience with her son “is not an isolated case” and that it illustrates the need for Morningstar. He pointed to several high-profile homicides and suicides involving mental patients in recent months as further signs of deficiencies in the system.

He said the massive deinstitutionalization of state hospitals in the 1970s was chaotic because there were few community supports for former patients. A safety net has developed since then, Szoke said, but “now we’re slowly pulling the community supports away” because of budget cuts. “What’s the difference between deinstitutionalization and now if people don’t have access to services?”

Hospitalization is the most expensive of the services funded by ADAMHS, whose total budget of $50 million is down $10 million from the time of Twin Valley’s closing. Board agencies serve about 19,000 people a year, the vast majority of them nonviolent outpatients.

Szoke said the Morningstar facility could save an estimated $2.8 million a year, to be spent locally for other mental health services. Unlike state hospitals, Morningstar could bill Medicaid and Medicare for its services, with ADAMHS paying only a portion of the costs. Morningstar would cost $200 a day, in comparison with $525 at Summit, which has an unusually long median length of stay — 78 days in 2008, compared to the 18 days Twin Valley had during its final year. The disparity reflects a treatment philosophy — Summit is less aggressive at moving patients, Szoke said — but that philosophy means far fewer patients can be treated for the same amount of money.

Even with the dramatic drop in the admissions rate to state hospitals, the county ranks only slightly lower than the state average, according to Dr. Ann Morrison, the chief clinical officer for ADAMHS, who oversees admissions to Summit.

“We’re providing access that is on par and even greater than similar counties and metropolitan areas,” she said.

Montgomery County logged 1,919 patient bed days at state hospitals per 100,000 population last year, compared with a state average of 2,009. However, Hamilton County, which also uses Summit, refers far more patients there. Last year the number of patient bed days from Hamilton County was more than double the number from Montgomery County.

Szoke thinks Morningstar can reduce the admissions to Summit even further, and thus save money, but the plan has drawn fierce criticism from GDAHA because the facility wouldn’t treat the most seriously ill patients formerly served by Twin Valley. In a letter e-mailed to community leaders, GDAHA officials said Morningstar would merely “add capacity to the one area where hospitals already have additional and underutilized excess.”

GDAHA president Bryan Bucklew said Morningstar “doesn’t make sense” because it would add long-term operating expenses to a budget already constrained by cuts. He said hospitals should get a payment from ADAMHS for hospitalizations beyond five days, and he called for a “top-to-bottom look at the system” with the hospitals having a voice in decision-making.

Sandra Stephenson, director of the Ohio Department of Mental Health, acknowledged that mental health funding is tight. She said the state offered to provide $2.5 million for capital improvements and $2 million in first-year operating funds for a proposed “crisis stabilization unit” on the Twin Valley grounds immediately after the closing, but Szoke rejected the idea, saying it would be too costly to maintain. Now the state budget has no money for Morningstar operations, she said.

Stephenson said GDAHA’s opposition makes her question whether the state should pull the $202,600 renovation grant for Morningstar it tentatively approved this summer.

She added that the hospitals’ push for more involvement “leaves me with hope that the local community will come together, clearly define the problems and look at what are the needs and resolutions to the problems in the community.”

No place to go

Jim Chase, longtime patient representative for Twin Valley, believes Montgomery County has slipped to the very bottom in the state for how it cares for its mentally ill population. “Every time you go by one of these hospitals, they’re building a new heart wing, but there’s nobody speaking up for these folks,” Chase said. “Many of them are indigent, and they have no place to go. They end up sitting in jail, or wandering around St. Vincent’s.”

David and Ramona Acord of Harrison Twp. know they’re among the fortunate ones; their 39-year-old son, who was diagnosed with bipolar disorder seven years ago, hasn’t been hospitalized since Twin Valley closed. During his five stays at Twin Valley he learned to be diligent about taking the pills he used to stash at various places around the house. “We owe the folks at Twin Valley a bunch,” David Acord said.

They don’t have the kind of problems that make headlines, but their story exemplifies the day-to-day struggles of families coping with mental illness. Their son’s weight has nearly doubled, to 325 pounds, in the past two years, in part because of his medication. He needs aortic valve replacement surgery for an unrelated health problem, but it can’t be scheduled until he brings his weight down. “The folks at Twin Valley did a good job of keeping him on the right diet and monitoring things such as how many Cokes he is drinking,” Ramona Acord said.

Because of their son’s medical and financial needs, they have been unable to retire. At 69, Ramona still works as a Dayton public school teacher; David, 72, has taken over his son’s successful salvage-yard business.

They worry about what will happen if their son needs to be hospitalized again and they can’t visit him every day in Cincinnati. “Our son’s very trusting and loyal and if he thought we put him away without visiting him, that could cause a real rift in the relationship,” David Acord said.

For parents like the Acords and Margaret Gerken, the closing of Twin Valley is a wound that won’t heal.

“Twin Valley was a life-saver for people in this area,” Gerken said. The closing “was devastating for our people. There is no recourse. There’s nowhere else to go.”