Notes from Region I DMH meeting, March 23, 2012, Huntsville Main Public Library, 10 am to 1 pm
(This may be of interest to those of you who are preparing for mental health cuts, but I am mainly posting it here so local Alabama advocates can review. DMH= Alabama Department of Mental Health, NARH is North Alabama Regional Hospital. As I’ve posted previously, the state is preparing to close all the large regional psychiatric hospitals except for criminally committed and geriatric, and move care into the communities. However, the communities are not ready. This was the last in a series of regional meetings around the state between DMH representatives and what they call “stakeholders”– family members, consumers, service providers, law enforcement, etc. It was a LONG meeting).
My general impression/opinion: DMH came planning to reassure us and give some broad platitudes. Long on “philosophy” and short on facts. Peacock told the press she expected us to leave feeling “more open-minded”. We quickly uncovered that they have NO IDEA what they are going to do—not reassuring at all. They do not even have an estimated cost analysis or desired timeline. They are saying that the regional facilities won’t close until local capacity is in place, but in the next breath, they can’t give a timeline because it depends on proration. So the truth is, they don’t even know if they will be ready before they are forced to close the hospitals because they can’t pay to run them.
Lots of use of “I agree” and “I feel your frustration” but the group was not taken in by these therapy tactics. I suspected the questioners were more well-informed than they expected.
I do not think it is DMH’s fault that the legislature is not funding adequately, but I am very frustrated that they are not following the example of other state agencies and being clear that they can’t cover services without $. They owe us the duty of presenting a clear budget need to the Legislature and a clear time-frame for transition, whether the government provides that needed money or not. They need to be clear in saying what the consequences of inadequate funding will be. It is unacceptable for them to be so passive in this circumstance.
Fortunately, the press did read the release and talking points I sent in advance and were quite pointed in their reporting—they could definitely tell that DMH was not providing the answers we requested. We also did a 1 hr sign protest in the pouring rain beforehand—made for some great TV footage.
Dr. Tammy Peacock began with introductory remarks/ background. Said Commissioner Zelia Baugh had planned to come but was in a finance meeting discussing plans to deal with proration. They do not know how they are going to deal with the 10.6 proration (21.2% cut in next 6 months). Discussed anticipated 29 million dollar cut in DMH budget for 2013. Said hospital budgets had already been cut as far as possible and that even closing only 2 of them would not be enough to cover a 29 million $ gap. Said other reason to close hospitals is that the Department of Justice is enforcing Olmstead ruling, which says that individuals with mental illness have the right to live in the most integrated setting they are capable of.
Peacock said no one had been comfortable with the October 1 timeline. They are still not certain of where funding to create the new community infrastructure will come from. They plan to overlay mobile crisis teams onto local MHC services, work toward tele-psychiatry 24-7, and leverage more federal dollars. They are not sure of plans for long term care of the most seriously mentally ill. They are currently talking to other states and federal agencies to get ideas. It is “not our intention to shift the financial responsibility to the local level.”
Peacock said the timeline is extended but they don’t know by how much. She then opened the floor to questions.
Questions/ Comments from floor (my occasionally snarky editorial comments in italics, and interchanges that seemed particularly significant to me in bold– I may have missed some, was writing furiously—please fill in if you notice a gap):
Q: If consumers were required to clean their facilities themselves, how much money would that save? (Really, someone said this—I almost fell out of my chair. Fortunately, it got better)
A: Consumers would need to be compensated fairly for any work they did
Q: Isn’t it a short-term solution to become dependent on federal $? And the questioner can’t tell when her relative with SMI is stopping meds—he would be capable of killing somebody if off them.
A: Most consumers would be able to live in their homes but some could go to supported housing. They have been in meetings with HUD. They will need ACT teams and PACT teams (a larger team) for the most seriously ill. (Did not answer the question about federal $).
F/U Q: But if my relative refuses treatment the PACT team can’t force him, right?
A: No, they can’t
Comment: HUD housing is in bad neighborhoods where people prey on mentally ill.
A: This is not about us saving money—reality is that we have 29 million less to spend. (not an answer)
Comment: Concern that outpatient commitment law has no teeth and needs to be revamped.
A: There will be inpatient care through “different means”. Alabama just hasn’t been sued “yet” because of restrictive care. (doesn’t seem like an answer)
Q: Is the state prepared to help local hospitals become designated facilities?
A: Contact your local MHC
Comment (mine): I disagree that we have too many people in restrictive care and are at risk under Olmstead. For Madison County alone, if 1.1% of adults over 18 have schizophrenia, national statistics say 5% should be in the hospital at a given time. That would be 140 at NARH for our county alone, just for schizophrenia. We have fewer served by the hospital and group homes than should be there, not more—what we need is MORE community services in addition to crisis and group home services. Told briefly about son’s experience with commitments and difficulty getting community services. Said that without adequate services at every level, people would cycle through repeatedly and each time they had a bad relapse, they could suffer permanent damage.
Answer: I agree but we don’t have the money (that was all she said. To me, that says she knows good and well that this Olmstead bit is blowing smoke.)
Q: Can you elaborate on the timeline for hospital closings?
A: The Commissioner is working with the Governor and hopes to announce next week. We are not going to close the hospitals until communities have identified local beds. Says there has never been a July deadline at NARH (for stopping new civil commitment admissions) and doesn’t know where we heard that.
Comment: A son has been committed 4x for mania but in between is fine. Risk of being hurt/ arrested when manic. Takes 3 to 4 weeks before safe out of a confined place.
Comment: Our Place (drop in center in Huntsville) needs more $ for peer-led services
Q: If Judge says a person is committed to the hospital, where will they go if no hospital?
A: No closings until we have local beds
Q: Where is the funding for new facilities coming from?
A: We aren’t going to put the bulk of our money into bricks and mortar. There will be “repurposing” of existing structures. We can’t do it without bridge $. (basically, they don’t know)
Comment: The cost of renovation is high—must do expensive items like replacing window glass, etc, not cheap
A: I agree
Comment: “It sounds like you’ve decided to sell us out”
A: That’s not my perspective
Comment: We need more research and funding to find early treatment for SMI
Comment: Concern about consumers who will be discharged too soon because they have learned what to say—doesn’t think ACT/ PACT teams maintain outpatient control without offending constitutional rights
Comment: the community is uneasy because of how the information was released. People don’t have enough info, being given conflicting information, changing info– DMH should have given better/ more complete info
A: I agree. Hard to be definitive when we don’t know
Q: Why didn’t DMH prepare for this earlier—they knew the budget situation was coming long before now
A: “It isn’t cost-cutting—nobody has $” (how is this an answer?)
Comment from consumer: NARH helped me tremendously
A: Closure is on hold until access at community level
Q: What is the probable time of hospital closure?
A: We don’t know—it depends on proration and funding. MHC’s have been asked to give a plan for what they need. There is a philosophical change to move to community care. (Philosophy, Shmilosophy… give us some facts)
Q (me): How much time and money do you actually NEED to do this right?
A: Can’t answer—“we can’t control the process” “we don’t make a wish budget”
Q: Is there a 5 year plan for how to evaluate/ monitor this transition?
A: Didn’t answer. Just said they would get feedback from MHC’s.
Q: Is there a plan to meet individually with MHC’s?
A: We have been meeting collectively, and some individual meetings are in process
Q: Can local hospitals serve as crisis stabilization and will $ be available to them?
A: talk to your MHC
Comment: Georgia did a similar transition to community care, and it was fine until patients decompensated and they did not have enough places to send them. Became a revolving door system.
A: Isn’t it already a revolving door system? (Wow—she really said that. How is that a helpful answer?)
Q: Have you pressured the fed govt for $?
A: Commissioner hasn’t asked yet, doesn’t know how many housing vouchers needed, “a lot of data hasn’t been gathered”
Comment: Real stakeholders have not been brought into this process. Crisis houses have failed in other states
A: They have applied for housing grants (first, doesn’t answer the question—second, seems to conflict with answer above but I may be misunderstanding)
Comment: Illinois closed a hospital in one area to rely on community services, then closed community services, and now churches are doing a rotation to care for the mentally ill (I have not seen this in print)
Q: Have you coordinated with the Sherrif’s Depts, State Police to find out needs?
A: Not sure. Did meet with Probate Court committee
Q: What about Deaf? Are interpreters in plan? Commenter noted that her local hospital was often not staffed to assist her 24-7.
A: Possible regional capacity. Haven’t figured it out (Note—there was a Sign interpreter present)
Q: The responsibilities of the Community Mental Health centers are increasing—how will we fund all this?
A: Never underestimate the power of your vote. (By this point, I think she realized we were serious)
Q: How will the MHC’s handle the 10.6% proration and handle new administrative responsibilities to develop these plans?
A: “No one has told the MHC’s they will have a 10.6% cut”. (umm… you said earlier that the hospitals could not be cut further at 25% cut—this will be a 21.6% cut over the rest of the fiscal year—how could it NOT come down on the MHC’s? Is there some secret department we don’t know about?)
Comment: You can’t answer our questions and can’t give us a plan. You haven’t done a cost-benefit analysis.
A: I understand your frustration
Comment: State has been trying to get out of hospital business for years. ECM (Eliza Coffee Memorial) hospital is limited to short term only. Communities have trouble keeping psychiatrists to staff local hospitals. How many on the planning committee are probate judges, family and consumers? 90% of commitments are recycled. (I didn’t hear the answer, sorry)
Comment: People get bumped from group homes to communities and then their families bear the burden.
Comment: It doesn’t just take resources to begin this project but resources to sustain it.
We broke into groups and discussed our needs, then reported back. I could not see the written lists of the other groups, but the verbal reports were very general—just basically needing peer support, law enforcement training/ support, more community capacity.
Madison County MHC group requested a long list of items by process of brainstorming, which I have because I was in that group. Note that Brian Davis, who has spoken to us about his own perspective previously, gave us a chance to tell HIM what we think we need. Thanks, Brian! I don’t know if the other groups did it that way.
1) 60 additional group home beds in addition to present capacity
2) 100 more supervised apartments and $ for setup/ furniture, etc
3) Ability to use larger than 3 bed homes if necessary for economy of scale
4) Private rooms in the group homes, for consumers who relapse from stress of no privacy
5) A mobile psychiatrist available 24-7
6) More peer support, another drop-in center
7) Young adult Peer Support and transitional support
8) Maintain current services at Huntsville Hospital
9) Consumer classes for communication skills/ assertiveness
10) A crisis stabilization unit ready before NARH closes
11) More timely access to appointments at MHC
12) Recruit/ hire more psychiatrists
13) Try to get some of the oil money for infrastructure
14) Respite beds for short term care, if family needs to be out of town or are ill
15) Flexibility in policies about who needs therapy and med monitoring
16) Mixed opinions on tele-psychiatry—some in favor, some worried about pinning too many hopes on it
17) More services for autism/ Asperger’s
18) DMH needs to tell the Governor and Legislature how much $ they NEED and not just take what they get
19) Transportation for consumers
20) More family members involved at DMH level in planning
21) More local planning sessions/ communication. Don’t call the meetings “stakeholder” meetings—should be town hall/ forums and should be well-publicized. The whole community is affected
22) More commitment from local government to be involved
23) Increase the skill level of MHC therapists
24) Some remaining capacity in the state for long-term hospitalization