When the state of New York closed many of its psychiatric hospitals starting in the 1970s, the intent was to house the mentally ill in alternative residential settings that were more humane and less costly. Instead, many mentally ill people ended up on the streets or in prison. In the Hudson Valley, the hospital emergency department has become the place of last resort, and hospital beds are housing mentally ill people because there”™s no where else for them to go, putting a huge financial burden on those facilities.
Take Saint Francis Hospital, which is the only hospital in Dutchess County that has a psychiatric ward. The demand for the care of often combative, disoriented individuals arriving at the emergency room greatly exceeds the capacity of the ward, which has 59 beds. Many patients stay far longer than is merited in an acute-care facility because of lack of space elsewhere.
“Saint Francis was never meant to be a full-term mental-home facility, but because there”™s no place to send people to, there”™s no place for them to stay but here,” said Bob Savage, Saint Francis”™ CEO and president. He said as of last August seven patients had been in the ward for as long as 69 to 229 days. That”™s equivalent to treating 67 patients staying 12 days, which is the hospital”™s average length of stay, said Savage.
He said the hospital can ill afford the cost: last year, it spent $1,325,000 more to care for the mentally ill than in 2006. That pretty much wiped out the hospital”™s bottom-line budget of $1.3 million, preventing the not-for-profit facility from making necessary re-investments in its facility and programs.
Savage said the hospital in some cases is absorbing mentally ill people coming from as far away as Syracuse or St. Lawrence because of lack of beds. When its own ward is full, it sends patients to facilities in neighboring counties or Manhattan, creating a hardship on the patients”™ families because of the distance.
Treating the mentally ill also is a drain on the staff. Savage said a mentally ill person who is aggressively resisting treatment and is physically ill may have to be watched around the clock, requiring up to a dozen employees. In addition, the hospital spends about $15,000 a month on legal fees. Lack of involvement from families and the unwillingness of a possibly suicidal or dangerous person to be treated in many cases require a hospital attorney go to court to declare the person incompetent so that treatment can be provided. Savage said this cost is going up as the incidences of severely disturbed people showing up at the hospital is increasing.
Savage said the mentally ill patients are also getting younger, with some children as young as 3 or 4 years old arriving. The hospital won”™t turn anyone away, although many of the mentally ill people are on Medicaid or uninsured and therefore “generally don”™t reimburse well.” “We have great difficulty placing patients from ED who are no-pay if we”™re full,” said Savage, referring to the emergency department. “We see ourselves as an acute medical-surgical facility and trauma center, but at this point, our other services subsidize these services.”
Dutchess County used to have two psychiatric hospitals housing up to 11,000 people, but today it has only one, the state-run Hudson River Psychiatric Center (HRPC), in Poughkeepsie, which has been downsized to 125 beds. Dr. Roger Christenfeld, research director at HRPC, said that the facility also takes patients from hospitals in Putnam and Ulster counties and is primarily an out-patient facility.
Ideally, people would stay at the psych center for a period of days or weeks and then find some type of independent or semi-independent living situation, but the bottleneck in available community residences is leading to much longer stays, which in turn has led to a waiting list for beds, he said.
While the median length of stay is 70 to 80 days, about a third of the patients have been at the HRPC much longer, in some cases for years. Christenfeld said the state”™s plan to provide funds for 500 more beds for the mentally ill “isn”™t enough,” although it will certainly help. “It takes money,” he said. Adding to the challenge is the “vastly rising cost of antipsychotic medication and housing.”
HRPC is providing a new service launched by the state called Assertive Community Treatment, in which staff go into the streets to treat mentally ill people who are homeless and in and out of prison. Christenfeld said the largest de facto institution for the mentally ill is the Los Angeles County Jail, with Rikers Island in New York City a close second. “We find an increasing number of patients come to us through the criminal justice system,” he said.
Despite the need, Dutchess County actually lost more than 100 beds over the past four years because some private community residences could no longer afford to stay in business, according to Dr. Kenneth Glatt, the county”™s commissioner of mental hygiene. “There is a dearth of affordable housing in general, and for the seriously mentally ill there is even a smaller supply,” he said.
Glatt said that 300 mentally ill people were transferred to hospitals in other counties between January and October of 2007 because Saint Francis was full, an average of 28 people a month. He said one young man who was dually diagnosed as having a developmental disability as well as a mental illness was at Saint Francis for over a year. According to testimony he presented last July to the Office of Mental Health (OMH), the state agency that oversees treatment of the mentally ill, of the 1,250 adults admitted to Saint Francis”™s psych ward only 65 were accepted for transfer to HRPC.
Glatt is pushing for an expansion of the HRPC. He also has asked OMH to allow mentally ill patients in Dutchess to be transferred to other hospitals in the state with excess capacity. He said plans by Putnam Hospital Center to add 10 beds to its 20-bed psychiatric ward could also help meet the need.
Dr. Howard K. Weiner, medical director of psychiatry at Putnam Hospital Center, located in Carmel and part of the HealthQuest network, said the hospital has become more pro-active in working with Putnam County to seek court orders for Assisted Out-patient Treatment. “We”™re working hard to provide comprehensive plans for patients,” he said.
He said that while there are some very good programs providing housing for the mentally ill, such as Search for Change, a privately operated program providing group homes with various levels of care, “there are bottlenecks. We do need more resources.”
“All of us working in this field face many complicated, competing pressures,” Weiner said. “In our search to provide the best treatment for patients, we have to balance their civil rights with the need for treatment. Unfortunately, sometimes their illness interferes with their ability to understand that need.”
In Orange County, St. Luke”™s Cornwall Hospital has been absorbing greater numbers of mentally ill people in its 22-bed psychiatric ward since the closing of a psychiatric center in Middletown in the 1980s. Because some of the mentally ill coming to the ED are not taking their medication, “they cause a huge amount of turmoil, so we need safety and security staff on hand,” said Dr. Catherine Polera, chair of the hospital”™s ED. While the longest stay in the ED is normally six hours, “there have been occasions when a mentally ill person is in there for 72 hours,”™ she said.
Polera said the main challenge is placing people in other facilities when the ward is full. “It”™s crazy, not just in our county but in emergency medicine throughout the state,” she said. Finding a place for children is particularly difficult and sometimes results in a mentally ill child traveling to Manhattan for a bed, she said.
With 1,000 in-patient beds and 500 programs providing housing and outpatient services for the mentally ill, Westchester County has the most comprehensive services in the Hudson Valley. Yet it also struggles with the need for more housing. Grant Mitchell, commissioner for Westchester County Department of Community Mental Health, said he is pursuing a strategy of mixed housing, in which residences for the mentally ill would be combined with housing for other groups, such as homeless veterans and working families. This would be a way to win more acceptance among communities, which is a huge problem in establishing more housing for the mentally ill.
“The problem is the siting,” Mitchell said. “It takes a significant amount of time to find a suitable location” because of the resistance. State statutes often require community notification, and “with larger type housing programs you can run into all kinds of problems.”
More funding is also needed. “The need far outstrips the supply,” Mitchell said. “As housing pricings have soared in the last five, 10 years, (housing for the mentally ill) has been squeezed.” His department is also focusing on providing more treatment services for mentally ill people who commit a crime, to avoid recidivism. That requires more money because it also deals with the criminal justice system.
Andrea Kocsis, executive director of Human Development Services of Westchester, a nonprofit providing housing and rehabilitation services to the mentally ill, said her group has 350 units, 66 of which are transitional residences. She said the organization provided housing for about 50 families living in shelters because of a mentally ill parent. Most of them are still in the housing unit, providing a much more stable situation for about 100 children.
OMH and the U.S. Department of Housing and Urban Development provide rent subsidies. But overall funding for the organization has lagged behind inflation, Kocsis said. While inflation increased 30 percent over the past 20 years, Human Development Services”™ budget increased by only 8 percent. She said over the last couple of years, the governor”™s office has shown more interest in providing funding.
Marshall Beckman, director of Community Mental Health Services in Ulster County, said his department is pushing for more “intensive supportive housing” for the mentally ill, such as clustered apartments with on-site supervisors. Providing housing to people with behavioral health problems who are often impoverished and sometimes physically disabled “is an uphill battle,” he said.
Beckman said there are actually vacancies in some of the county”™s minimally supervised apartments for the mentally ill. “Either the client doesn”™t want to live alone, or the agencies sponsoring the housing feel they just don”™t have enough resources to manage people,” he said. Housing for mentally ill sex offenders is a particular challenge.
“These people need a tremendous amount of support,” said Beckman. “Sometimes these people are so taxing to the system the agencies just can”™t handle them.” People who are both mentally retarded and mentally ill in some cases languish in the psychiatric ward at Benedictine Hospital as the hospital struggles to find a place for them in the community, he said.
“Most of us feel there”™s been too much downsizing of the state psychiatric hospitals relative to the types of resources in the community,” Beckman said. “We”™re still playing catch up.”
