Saturday, January 11, 2014

Let's Have a Task Force!

I'm going to do a little problem solving here. 

In the Washington Post yesterday in Virginia Doesn't Need Another Mental Health Task Force,  Pete Earley writes:

Virginians should be embarrassed and angry that a newly appointed state mental health task force convened Tuesday in Richmond. It is the 16th task force asked to investigate the state’s mental health system.

If you click through to hit the link, you'll note that this 16th task force on mental health has 36 members.  Politicians love task forces, it's a way to look like something is "being done" without actually doing anything.  So now 36 people, presumably on someone's payroll, have to coordinate their time to be at these meeting, write reports, and in this case, reinvent the wheel.

I'll point out two other quotes from Mr. Earley's commentary, and then I'm offering my suggestions on how to fix the problem to the State of Virginia at no cost, here on my free blog, and all 36 of those people can go home and spend quality time with their families.


Virginia’s inspector general warned in a May 2011 report that 200 people were turned away from hospitals during one 12-month period because of a lack of beds, even though the patients were considered a danger to themselves or others.

Virginians must look at the big picture. After the Virginia Tech shootings, our task force lowered the criteria for involuntarily committing someone into a hospital. While a positive step, this has proved ineffective because there are not enough hospital beds. Meanwhile, 80 people in state hospitals are ready to go home but can’t leave because there is no affordable housing in their communities. It costs $590 per day to keep those patients in a hospital. It would cost $120 per day for them to live in a community setting. You can’t fix one tire and expect a car to run if the other three are flat.

So in my state (Maryland), the average length of stay in a psychiatric unit is roughly 7-10 days.  For certified patients, it gets a little longer, more like 14 days.  In Virginia, we're told,  200 patients/year are released from ER and I'll assume they have similar lengths of hospital stay.   Distributed evenly over the year, we're talking roughly 7.67 hospital beds if each of those patients stays for a full 14 days.  Let's be generous here; let's say that you need a few more beds in case the patients don't distribute their admissions evenly through the year, so let's give the State of Virginia 12 extra beds for their population of 8.2 million.  It seems they need one new psychiatry unit in a general hospital, or one extra bed in 12 units around the state. All this fuss for a dozen, or less, hospital beds?   

But Mr. Earley also points out that the state could save money by moving state hospital patients who are ready for discharge to a community setting, so presumably they don't even need to build a new facility, they just need to move a dozen patients to a community setting.  I imagine the cost to run a state hospital is a fixed cost, so the total cost of doing this is the $120/day/patient cost of moving those 12 patients: or roughly $500,000 year.  Chump change to get treatment for 200 dangerous people.

One last suggestion to Virginia: change the law requiring a hospital bed be found within 6 hours of a judge issuing an order for hospitalization.  I'm imagine the law came about because people were left in ERs for days at a time, as they are here in Maryland, so a humane requirement to move the process along is fine, but a law? And six hours?   In that time, I'll assume the police have to get the patient, transport him/her to the ER, get through triage, clarify health insurance, do vital signs, lab work, medical clearance, psychiatric evaluation-- including discussions with family and the patient's doctor, and locate a bed (a process that entails 'calling around' (--might I also suggest they set up a Google Form that hospitals could update a few times a day with their bed availability?)-- in six hours.  Maybe the patient gets brought in and doesn't need hospitalization? -- There was a misunderstanding, or he's acting strangely because his blood sugar is low, or she ran out of medicine and just need to be restarted on it....but those things take more time.  Sometimes, after a patient calms down (-- having the police grab someone makes everyone angry) and gets a thoughtful look and perhaps medications, then a few hours for the medicine to take effect,  and the patient may agree to sign in voluntarily. As I noted above, this makes for a shorter average length of stay.  Other times, the patient can be sent home, but a psychiatrist in an emergency room can't know that until he's had a chance to observe the patient for a while,  and to clarify what the outpatient follow up might be and what setting he is sending the patient home to.  

 I don't know that the laws we have in Maryland are any better than those in Virginia.  We also have problems with access to care, both inpatient or outpatient, and we also have our own mega-task force : the Continuity of Care committee.  Sometimes I wonder if common sense could take care of some of these issues, but as Pete Earley notes, it requires taking a stand and then moving forward, and change is hard.  I am starting to think that in Virginia it sounds to be very easy to get a gun and very hard to get mental health care.



CatLover said...

I have changed my opinions in recent years. I think that long-term grinding poverty, which is the lot of most people with serious mental illness, is directly preventing recovery and causing relapses. The daily stress of poverty is unbelievable. If a person gets government income support, there are volumes of paperwork to fill out to keep it coming, and how is someone with serious problems supposed to do that, and in a timely manner to boot? While on an antipsychotic? Ah, a social worker person can help. But do you know, 3/4 of what they do is fill out paperwork to keep themselves coming? I am utterly disgusted with the fake help provided by folks who are supposedly mental health providers.

The social worker types and their bosses love to throw out the little action phrases like "facilitating recovery." A lot of them are nice people, but incredibly, *amazingly*, ineffectual on every level. Even when very specific help is asked for, within the scope of their job, they somehow screw it up. What they are damned sure to do is make sure all clients get their Medicaid forms filled out, so the county and/or state won't be entirely on the hook for costs. DAMNED sure. Plus the paperwork that makes sure they can keep coming to the home and do nothing.

Of course, I'm not addressing spree shooters - it seems the spree shooters don't usually come from chronic poverty - they are earlier in their mental problems, before the catastrophic economic fall. People who are chronically poor can't afford the fine firearms these spree shooters use.

The truth is, if a mentally resilient person were forced to live in poverty and despised by all because of a label, and filled up with antipsychotics, they wouldn't stay mentally healthy for long. Society spits on this group of people then blames genetic factors for why they don't get better. Being a pariah keeps people sick.

I dunno how it is other places, but this is how it is where I am, an area with many low income rural people. If you don't have family to help you, you're screwed. Of course, a lot of times the family IS the problem, and that's where I get so disgusted with these blogs talking about these loving families with their wayward mentally ill kid, and oh my, they can't get them help and they are so loving. . . everyone I know with really bad problems has a problem family. But you won't read that on those forced care advocating blogs. The family is always blameless and the son or daughter just paranoid.

I also think psychiatric drugs are directly impeding recovery in a lot of cases, based on my own nightmare with those drugs, and I'm grateful many psychiatrists now acknowledge this. How about spend less on Latuda?

Joel Hassman, MD said...

Just remember what a colleague very astutely pointed out to me last year:

Common sense is the exception these days!

Come on, politicians hate mental health issues, for at least these reasons:

1. the mentally ill don't vote as a sizeable majority, so who cares what they think and need. I have been told a politician said that at a fundraiser years ago.
2. politicians themselves have mental health issues more often than not, if you count personality disorders as a mental health issue, and they don't want the attention to themselves.
3. Mental health care costs money that is not quantifiably justified, because how do you measure mental health improvements, versus follow up cardiac or cancer assessments.
4. Society still is biased and discriminatory, and live by the adage "NIMBY" regarding mental health and substance abuse services/beds in their communities.

Deeds, not words are what define people. The politicians en masse do not care about mental health, until a sensational case happens that gets public attention. So, a Virginia legislator was stabbed last year, how long will the outcry last?

How long did federal efforts play out after Giffords was shot in Arizona? A year at most?

But, if it was McCain, or Pelosi, or even Cantor who was shot or stabbed, well, then you would see action.

For about 6 months longer!

That is not a jaded or cynical comment, at least not by themselves. No, that is at least equally painful, hardened realism being written here. And as I posted last night, people here in this state should be worried more about the coming legalization of pot in Maryland. One of the reasons it will be a final nail in the coffin for Community Mental health services, at least in MD.

I'll be posting on that by early next week. It's raining today in MD, how much of my state taxes are washing down with the runoff?!