Subsidizing Psychiatric Treatment

[Davey Do]

In the past, the State would subsidize Services to its Mental Health Hospital for Clients without Insurance Benefits. Indigent Clients, if you will.

It appeared that the majority of Clients who were admitted to the State Facility were truly in need of Psychiatric Treatment. They were typically psychotic and unable to adequately function in the Community. So, that was a good thing: People in need of Psychiatric Treatment could recieve Services whether they had Insurance Benefits or not.

Then, in order for the State to save money, a portion of the State Facility was closed and Services were farmed out. The General Population of Psychiatric Clients were to receive Treatment from Community Hospitals. This seemed like a pretty good idea in theory: The State would no longer have to pay the cost of keeping the General Population portion of the State Facilty open and the Community Hospitals could benefit from recieving reimbursement for Indigent Patients.

This Plan worked well until the State ran out of the money necessary to reimburse Community Hospitals for Indigent Clients. The money ran out, Hospitals were no longer being reimbursed costs, and it put a real financial strain on them. The Hospitals continued to be responsible for treating the Indigent Clients, but usually had to eat the costs. One cannot get blood out of a turnip.

As mentioned previously, a majority of State-Operated Hospital Admissions were due to an Altered Mental Status. The other reason Patients are admitted to a Psychiatric Facility is due to being a Threat of harm to themselves or Someone Else. So, basically, a Person could walk into an ER, say they were thinking about committing suicide or hurting someone, and could be be admitted for Psychiatric Treatment.

Sweet! All a Body had to do was be THINKING about Suicide or Homocide and they got "Three Hots and a Cot"! FREE!

So, hypothetically speaking, an Individual could leave one Hospital after, let's say, a week's stay, go down the road a bit, enter into another Hospital's ER, proclaim a suicidal status, and be admitted for another week! Wow! Can you say "Recidivism"?

Everybody could have benefitted from this Situation. The State could have saved money, Community Hospitals could be filled to capacity with so-called Paying Clients, and Indigent Individuals could be recieving Needed Treatment while meeting some Basic Physiological Needs.

However, the abuse of a System will often bring its downfall: The State can't support a Revolving-Door Clientele, Hospitals have to paid in order to operate, and the Monkey on a back will have to have their Fix.

So, in order to deal with this Situation, some of the Rules changed. Hospitals would not Rubber Stamp a Psychiatric Admission for a Client without Insurance. For example, if a Prospective Psych Patient in ER was voicing suicidal ideations, and had a high BAL, the Individual was required to be reassed. Once the BAL was below the Legal Limit for Intoxication, reassessment took place. In the majority of the situations, once the effects of the alcohol wore off, Prospective Patients were no longer suicidal.

Hospitals have also dealt with the high number of Indigent Individuals attempting to be admitted for dubious symptoms by limiting the number of Psych beds available. When "There's no room at the Inn, Mary and Joseph", we Divert.

In summation, there are limited Inpatient Psychiatric Services available. There are, supposively, more Individuals out on the streets with Suicidal and Homocidal Ideations. I wonder how this will fare. I guess the Proof will be in The Pudding.

Thanks for reading my topic. Let me know what you think.

Thanks.

Dave

[Whispera, MSN, RN]

Everything you wrote is how I've seen things happen. I don't have experience with a state hospital, but do with a general hospital with a psych floor, and with a totally psych hospital. The first had space for 60 patients and was often full. The second had space for many more and was usually full.

Back in the day, patients often stayed for about a month, but many of them couldn't pay for their care and/or had no insurance and/or had not-enough insurance. Someone had to pay for their care and that someone was whichever hospital they were in.

I did psych assessments in the ER for awhile. All someone had to say, whether it was true or not, was that he or she was suicidal. That meant immediate admit. I'm certain some needed food and shelter and not psych treatment. Their need is a community problem in itself, but psych providers couldn't keep providing for their needs and still stay available for those who were more appropriate admissions. Dollars only stretch so far.

After awhile the general hospital closed its psych floor and no longer treated psych patients. The psych hospital has been taken over by a general hospital, I'm sure due to financial problems. Where do their appropriate patients go now? Does this mean there are more psychiatrically disable people out in the community, trying to make it? Sure it does! Does that mean that there's more hopelessness? Definitely.

Thinking back to the 60s, I forget the name of it, but there was some law passed to have communities take responsibility for their psych patients, rather than having inpatient hospitals do it, and there was some funding for it. That was all well and good, but the law sprang forth before communities could develop reasonable outpatient treatment plans and many deserving patients wandered aimlessly, caught in their illnesses without any treatment available at all. I think communities are still trying to catch up.

It's all very sad and makes me angry too. What are people supposed to do? Just die?

(off soapbox)

[Davey Do]

Thanks for your great reply, Whispera. In no way did I sense you were standing on a soap box. Heck, if you believed you were standing on a soap box, then my soap box was pushed up right beside yours!

I, too, have known of Hospitals that have closed their Psych Units because of funding and other risks. No doubt the profits don't always match the energy expended, along with the stigma Mental Illness carries with it.

You mentioned Community Funding for Psych Patients- I was involved in a Program in the mid 90's that attempted to de-institutionalize the Chronically Mentally Ill and transition them into the Community. It had its sucesses and failures. I recently heard it is now defunct.

Something which amazes me is the fortitude some of these People dianosed with Mental Illness possess. Their ability to survive despite their inability to have a consensual perspective on reality is amazing!

An Algebra Instructor used to encourage us to find the answers "by hook, crook, or neighbor's paper". I believe This Population will survive by whatever means necessary, whether they be fair or foul. Of course, the easiest method to meet needs will always be the first option of choice. And, as with everybody else, if something's not provided for them, they will take it for themselves.

Dave

[PsychRN98, ASN]

I feel a great disservice has been done to the mental health community by closing the majority of psychiatric State Hospitals. They were working, making a few bucks, feeling useful, finding comfort in the solidarity of peers, and most importantly, being treated at the same time for their illness. Now granted, way back when some bad things were happening in psych of course, but I think the state hospital system should be reinvented. There are so many beatiful old buildings rotting and even more beautiful old sick people rotting on the streets, b/c they are unable to care for themselves. This was especially evident when the closings first started happening. How can you take so many people, who have only known institutional living, and expect them to care for themselves, with such severe illness? Anyway, I naturally agree with mental health care needing reform and more money being spent on it. Hasn't anyone that matters noticed that so many medical pts. also have untreated mental health issues? (don't we all?...lol)

Great topic Dave!

[Davey Do]

How can you take so many people, who have only known institutional living, and expect them to care for themselves, with such severe illness?

Of course, RNandmommyto2, you know that your answer is within your question. And a profound question it is.

It is a fact that is as plain as the proverbial nose on One's face: Some Individuals cannot function adequately in Society.

I've worked with a few different Methods of Residential Mental Health Settings. For example, some Mental Health Clients live in the Community and are regularly visited by Mental Health Professionals (MHP's). Others live in an Assisted-Living like situation where MHP's actually work on the Premises. Still, there are other situations where Mental Health Clients reside in a LTC Facility and, along with the Programs of the Facility, are Monitored and Programmed by MHP's.

All of these Methods successfully provide needed Services to the Clients IF the Client is appropriate for that particular Service. However, not all Mental Health Clients can successfully transition, even within this framework, from Institutionalized Living to Community Living. A Fish out of water cannot be expected to survive, so to speak. And an Psychotic Undifferentiated Schizophrenic who has a history of Medication Non-Compliance and Substance Abuse cannot adequately function otside of the realms of Close Clinical Monitoring.

It now seems, unless a Mental Health Client has committed a crime, the Client is not eligible for Institutionalization. As a result, the Client will be set free in the Community to fail again and recidivistically return to a Hospital for stabilization. Such action takes its toll on the Client and expenses. Such is life.

Anyway, I thank you for yor comment and kind words, RNandmommyto2.

Dave

[NPvampire, MSN, RN, APRN]

Get ready for some suds...

Our state is in the process of closing its state institutions. They have already closed all of them for child and adolescent. The private hospitals won't take kids without insurance. The ER has nowhere to send them. There are only a small handful of community crisis beds available, most of which will also refuse truly violent patients, nor will they hold for court evaluations. This dumps the violent kids back into their (often) violent families, the prison system, or worse. The move to community centers sounds wonderful on paper, but the community is not trained or equipped to handle the most violent mental patients. And, there just are not enough community beds b/c they didn't get the extra funding when the big hospital closed. The very, very long-term'rs they pretty much just let loose into the community, or trumped up a charge to move them to forensics, although a few might have been accepted at PCH/ALFs...maybe.

The closing of the institutions hasn't worked! It just lets the mentally ill out onto the street to die, get jailed, commit violent crimes, or wander homeless. Yes, that's much less cruel than inpatient treatment!

I do see a LOT of "frequent flyers," though. Yes, the state pays part of their care. Part of the recidivism is the placement--if they do not have a supportive home/relatives/PCH to go to, they are much less likely to follow up with their outpatient care and medications and keep sane. Another part is the meds themselves: hello, it does NO good to put an uninsured (or most insurances) patient on Synagis, it's 1300 dollars per shot per month...hullo McFly...yeah Haldol's side effects suck but it's better than getting killed on the street because you are fighting strangers or gang members because of your voices in your head...docs need to kick out the pharm sales reps and kick their brains into gear. Stop putting brand-new uninsured patients on the brand-newest drugs they can't afford...Risperdal has a generic--try that first!

There is just as much "frequent flying" at the crisis centers that do drug and alcohol rehab mixed with mental health. They come in, take up the bed, get sober, and go right back out and use the drugs again. Then they come back the next week--usually after they have been kicked out of their home/hotel. I think that something needs to be done about that situation and the money it drains before closing the hospitals and throwing the chronically mentally ill on the street.

And don't think forensics is exempt...they close those units also and just crowd them into other forensics mental health hospitals. Some patients are 5-6 per room! Lucky they're not the really violent ones.

Ugh, this topic really lights my fire! If I ever win like 500 million dollars I am going to reopen the largest state hospital!

[Davey Do]

Suds duly noted, RNvampire. Your Post reinforced Perspectives and added Stark Information.

Re: the use of new drugs... In the past, at two different Mental Health Clinics, I set up and ran Patient Assistance Programs for Psychotropic Medications. The Drug Companies supplied psychotropics, free of charge, to Individuals who could prove they were financially in need. Having not been involved in this area for about the past eight years, I don't really know the current status of these Programs.

As far as the Other Points you made, I'm at a loss... I have no idea what to do about the situation, short of contacting Political Officials. We all know the Wheels of Government turn slowly, if they ever turn at all.

I'm thinking that the Potentiating Factor for Change may just come from something like a Pandemic Crisis. You know, Anarchy in the Streets as a result of the Current Situation, causing a Change of Venue.

Time will tell. Thanks for your comment, RNvampire.

Dave