Category Archives: mental health

Talking Points for Madison County in Response to Alabama Department of Mental Health (DMH) plan 2012

Talking Points for Madison County in Response to Alabama Department of Mental Health (DMH) plan 2012

 (Please add to this for your county by working with your local NAMI Chapter)


The DMH is planning to close 4 large regional psychiatric hospitals and transition care to local communities, in order to meet severe budget shortfalls for the 2013 fiscal year.  Here are some key points citizens need to address:


1.  In order to fulfill the court-ordered treatment of patients who are committed, we will need crisis stabilization units.  Local hospitals are not prepared to accept these patients and do not have the capacity—their beds are already over-full with acute care patients.  Our MHC has applied for a 16 bed unit.  If nearby county mental health centers (MHC’s) also get the units they have applied for, we can meet or exceed our current capacity at North Alabama Regional Hospital (NARH).


2.  Money and time is needed to prepare the crisis units.  The closure of NARH is planned for September 2012, but NARH plans no new commitment admissions after July 1, 2012. There will be no time or money to build a new facility.  That leaves less than 4 months to locate, purchase and convert an existing facility. DMH does not plan to provide these capital funds, so our MHC will have to apply for a loan once they find a suitable location.  The MHC has requested a budget to operate the units but has not received a figure for what our county will receive.


3.  There will be potential barriers to purchasing a suitable facility.  Our community has a history of “not in my backyard” responses to various forms of subsidized housing and group homes.  It is unknown how much time/ effort this will require to overcome.


4.  Once a facility is purchased, the renovation requirements will be extensive.  For example, all existing glass windows will need to be removed and replaced for patient safety.  Showers will need to be redone so that there are no rods for patients to hang themselves on.  There will need to be “crash bars” installed and safe furnishings purchased.  Doors, both internal and external, will need to be secured and fencing must be erected.  The crisis units will be used to stabilize the very sickest patients—those who are actively trying to kill themselves, are homicidal, or otherwise severely psychotic.  For their own safety and the safety of the community, the facility must be properly prepared.


5.  It is unrealistic to expect the crisis units to be complete in less than 4 months, when a site has not even been located nor a budget amount provided.  The MHC is not to blame, because they have only been informed of the plan within this month.   Our MHC will work as quickly as possible, but there is NO WAY they can have this finished by July 1 in order to accept commitment patients.


6.  Current group home residents who have been stable in their placement are now being “bumped” to less supervised settings in order to make room for those being discharged from NARH.  Many of these bumped patients have a history of multiple relapses and re-commitment.  Without a facility for new admissions, there will be no place for them to go. DMH does not plan to fund expansion of group home beds. 


7.  We appreciate the DMH’s concept of community care and less restrictive settings, along with the “recovery” orientation.  However, national statistics tell us that there is a certain percentage of patients with serious mental illness (SMI) who will always require more intensive support than supervised apartments can provide.   Our MHC’s are NOT failing to provide the care that would cause recovery—there is simply no known cure for these tragic illnesses.


8. Madison County, according to the US Census Bureau, had a population of 334, 811 in 2010, 255,460 of whom were over 18.  According to national statistics, 1.1% of those over 18 will be diagnosed with schizophrenia, usually in the young adult age.  That means we should expect about 2810 of our residents to have this diagnosis.  Of those, national statistics tell us that 8% will have recurrent exacerbations despite treatment, and 35% will have exacerbations with a worsening function over time that never returns to baseline.  After 10 years of illness, 5% are expected to need hospital level care at any given time.  For our county alone, that would be 140 people expected to need residential care in the hospital. If we have only 16 on average, that means we are already well below expected numbers and that our MHC is not underperforming.  Even with current MHC group home beds at 60, we are utilizing less highly supervised care than expected.  And this is only for schizophrenia!  We also have illnesses like bipolar and chronic depression.


9.  Our families are filling the gap now, but we are already overburdened and cannot do more.  We applaud the plan to increase independence and integration into the community for those who can be helped in this way, but we must acknowledge the reality that some with mental illness cannot live this independently.  Our MHC cannot be expected to provide a magic bullet cure when no one in the world has been able to do it.


9.  The consequences of failing to transition safely to community care are grim.  Even with current services, 10 to 13% of those with schizophrenia eventually kill themselves.  Up to 60% of male patients attempt suicide during their illness.  If we set up a revolving door between group homes, the community, and re-commitment, there will be even more suicides when those who are most ill fall through the cracks.  If there is not even time to prepare safe crisis stabilization units, the risk will be even worse.


10.  Most mentally ill patients are more likely to injure or kill themselves than others.  Although violence against others and homicide is rarer, when it does occur, it is overwhelmingly more likely to happen to a caregiving family member than to a stranger.  Nationally, as many as 6% of patients with schizophrenia are in jail at any given time and 6% are homeless.   There is no rational way to bypass our need to provide adequate services—we will pay for it one way or another.


11. Of all the budget shortfalls, a failure to fund treatment for mental illness will be the quickest to show up in tragedy.  Failing to fund education may take years to be seen in a less prepared work-force.  Failure to fund Medicaid may take months to be seen in higher illness and disability burden.  Failure to treat our seriously ill residents, because of their severe fragility, will take DAYS to result in deaths.  We cannot afford to roll these dice.


12.  Please contact your legislators immediately, as well as the Alabama House and Senate committees preparing the budget, the Governor’s office, and any community groups you think might help us speak up.  Time is of the essence. Tell them we MUST fully fund the DMH and we MUST have more time to prepare this transition.


Please see my other blog post for more.

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Filed under Alabama legislative session 2012, citizen responsibility, mental health, specific advocacy ideas

Alabama’s Budget Canary: Funding the Department of Mental Health

As you know, our state is woefully short of the amount it takes to carry out our basic functions, and legislators have been acting like teenagers about it—shrugging their shoulders, rolling their eyes and saying “oh well!”’.  Many of the shortfalls will not show up in immediate damage.  Inadequately funded schools will result in a poorly prepared workforce, and proration to universities will eventually limit quality to the point our students invest tuition money elsewhere.  Loss of support for Medicaid and AllKids could result in poorer child health (and yes, even death from conditions not treated in time), but this could take months to show up.


The delayed nature of these consequences allows legislators to get away with it, for awhile.  One program on their hit list, the Department of Mental Health (DMH), could prove the exception to that rule. 


Our DMH funds three basic divisions—Developmental Disabilities (formerly called mental retardation), Substance Abuse, and Mental Illness.  In the planned budget, mental illnesses will take the entire cut to the department.  I am told that this is likely because the opposition to cuts for developmental disabilities would be too heavy, in the form of service mandates, lobbying groups, and potential lawsuits.  Addiction treatment is so minimally funded that there is nothing left to cut anyway.  So that leaves mental illness.


I would not want to be Zelia Baugh, our state’s mental health commissioner.  She has an impossible task.  The DMH pays out funds two ways, for operations, including at state owned facilities serving those who are committed by probate courts or criminally committed, and for contracted services by county mental health centers (MHCs).  The MHC’s also bring in money from private insurance payments and sliding scale payments by patients, but they are heavily dependent on the DMH money.


Baugh had a choice between cutting payment to the MHCs, already running on less than they need, and cutting payment to the state facilities, also underfunded, or both.  If she had cut MHC money, the centers would have had to let large numbers of staff go.  Patients would have to wait significantly longer than they already do, and for some of the most fragile patients who had barely been managing in the outpatient setting, the loss of access would have caused rapid increase of hospitalization and civil commitment.


The state facilities probably could not have been funded less and still stayed in operation.  So Baugh, under the gun, decided the only option was to close the state facilities almost completely.  The patients formerly at Taylor Hardin, for the criminally committed, will move to the new Bryce.  Mary Starke Harper in Tuscaloosa, the hospital for geriatric patients, will remain open because it is funded with Medicare money.  Everything else will close.


DMH plans to transfer care of committed patients to local facilities, as part of an overall strategy to integrate persons with SMI into their communities.  This could be a great plan for many patients, but for some it is unrealistic—I’ll cover the “philosophy” aspect in a later post.  So where are these local facilities?


Ah, there’s the rub!  There are no such creatures.  All over the state, MHC’s are scrambling to figure out what to do.  I am the secretary of our Huntsville chapter of NAMI (National Alliance on Mental Illness)—NAMI is an advocacy and support organization for families of persons with SMI.  We are not opposed to more community care.  We just want to be sure it gets done correctly.

 I met with Brian Davis, the director of the Madison County MHC, along with several NAMI members and board members, this past Thursday evening.  Brian kindly spent 1.5 hours answering our questions and explaining what our MHC is trying to do.  I’ll cover other community services later, but for patients newly committed to hospital care, he has asked for funding to run a 16 bed crisis unit (more than 16 beds would disqualify them from billing Medicaid).  If the adjacent counties also get the beds they’ve requested, there will be an equal or greater capacity than we previously had at NARH for our area.


He has submitted a budget request to DMH, but unfortunately he will not have any real idea of the planned funding for several weeks.  The state hospital in our area, North Alabama Regional Hospital, is projected to close along with the others at the end of September (because of the fiscal year), and that would be hard enough—but NARH plans to close to new civil commitments as of July 1.  That means he must locate a suitable building, renovate it, staff it, and be ready to go in less than 4 months.  He can’t start until he knows about the money, so make that less than 3 months.


To compound matters, he expects DMH money to only apply to operations for the crisis unit—it won’t cover capital.  So he will have to get a loan for our MHC.  He will have to locate a suitable building (not time to actually do new construction), purchase it in the face of the usual NIMBY outcry, and do extensive renovations.  Patients aren’t committed here unless they are considered a real threat to themselves or others—that means he will have to replace all the window glass and install “crash bars.”  He will have to get safe furnishings.  Even details like the showers have to be right—otherwise patients could hang themselves on the shower bars.


Are you getting the picture?  Do you think there is any way in heck all these tasks can be completed by July 1, or even September 30?  I sure don’t.


I asked Brian what it would take to do this right.  He told us he would need twice the expected money and three times the time.  If he had that, he said, he could do a GOOD job for us, and the outcome would be improved services for persons with SMI.  Money buys time, so that’s our first priority.


Back to the consequences of failing to be ready for this transition.  It might help to look at other states that cut services.  It is a grim picture.  Most mentally ill patients who kill or hurt people target themselves, not others—we can expect an immediate increase in death by suicide.  For those who do attack others, it is usually a care-giving family member who gets hurt or killed—the same family members struggling desperately to make up the gap in state services.  Speaking as one of these family members, I can tell you I am more afraid of what the state would likely do to my loved one—execution—than I am of dying myself.  But given the high frequency of SMI, we should also anticipate the rarer public violence to increase. 


We will pay, one way or the other—in money or in death.


I know I’ve asked for a lot of action on your part this year.  I hate to constantly have to tell you the sky is about to fall or that the alert level is red!  But it’s just that way.  You, my friends, are holding up our sky. 


Many of our fellow Alabamians with SMI can do well with proper treatment, but their mental health is very, very fragile.  A disruption in service can send an apparently stable person over the edge in a matter of days.  We will see disaster not in years, as for education, or months, as for Medicaid, but DAYS.  I’m not saying we should pass the planned cuts to those other programs—we should not.  We should tell our legislators to do their jobs and come up with the money, no matter what campaign pledges they have to break.  Otherwise Alabama will go down like the Titanic, with our statehouse playing the no-taxes violin on deck while we prepare to drown.


Your efforts so far have been productive.  The sneaky planned privatization of Medicaid, initially termed a “done deal”, has at least for now been slowed down.  The attack on women’s health services in the form of SB 12 has been met with such loud public outcry that the bill sponsor is backing down.  Keep pressure on—it works!  Tell our legislature to give the MHC’s money so they can buy time to do this right.  I’ll post a separate list of talking points for my county—please help NAMI Alabama add to it by investigating plans in your area.


Efforts are already in place by NAMI chapters in our state and NAMI Alabama, but family members burdened with providing in-the-trenches care to their loved ones can’t do it alone.  We are all affected by the mental health of our state.  Get in there and fight with us, shoulder to shoulder! 


Filed under Alabama legislative session 2012, citizen responsibility, mental health