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Preserving Essential Mental Health Services if General Hospitals CloseAn Opinion by Michael B. Friedman, LMSW
The Mental Health Associations of NYC and Westchester have become very concerned that The Commission on Health Care Facilities for the 21st Century could produce recommendations that inadvertently result in the loss of vital behavioral health services. With a grant from the New York Community Trust, we have formed a taskforce of over 25 umbrella organizations representing providers, professionals, families, consumers, and counties to call for a rigorous planning process regarding behavioral health services and to assure that vital services are preserved. The Governor, with the support of the New York State Legislature, established the Commission in 2005. The Governor has characterized its goal as “rightsizing” the hospital and nursing home systems, leading to the Commission being nicknamed the “hospital closure commission.” The Commission’s Director maintains that this is a mischaracterization of its goal. Its goal, he says, is to assure access to health care in New York State while also holding down Medicaid costs. This is certainly a sensible goal. But many of us have become concerned that behavioral health services will be neglected by the Commission as they focus on big ticket cost items. Because mental health and substance abuse services constitute less than 10% of hospital costs, they are a minor matter from the standpoint of those looking for big savings. From the standpoint of the mental health system however, general hospitals are anything but minor. In fact they constitute 37% of all spending on public mental health in NYS and provide 65% of psychiatric hospital beds. They also provide crisis services, outpatient services, case management, assertive community treatment and more for many thousands of New Yorkers each year. It is also important to keep in mind that while overall utilization of beds in general hospitals hovers around 65%, utilization of psychiatric beds is closer to 90%--nearly full utilization. There are quite a number of hospitals in NYS with very low utilization of medical-surgical beds but high utilization of psychiatric beds. Thus, decisions based on overall utilization of hospitals rather than on utilization of behavioral health services could result in significant losses of heavily utilized psychiatric facilities. The fact of the matter is that New York’s general hospitals are a key element of the system of community-based services that was devised in the late 1970’s in response to the failures of deinstitutionalization. Over five years starting in 1968, NYS went from 80,000 beds in state psychiatric hospitals to 40,000. The result was disastrous for tens of thousands of people, many of whom moved into squalid and dangerous single room occupancy apartments in very poor neighborhoods or into adult homes unprepared to serve them. It was also very tough on the thousands of families who took their relatives in. In 1978, New York State responded to the failures of deinstitutionalization by introducing the community support program. Housing, rehabilitation, case management, and other community supports were put in place to help people with psychiatric disabilities lead tolerable lives in the community. Outpatient services were expanded in community mental health agencies, state psychiatric centers, and general hospitals. The state also approved expansion of psychiatric beds in local general hospitals in preference to maintaining beds in overcrowded, low quality, often dangerous state hospitals. This policy also allowed the state to replace state dollars with federal Medicaid dollars. In essence NYS created a tripartite structure for community based mental health, a structure composed of expanded community mental health agencies, smaller and much improved state psychiatric centers, and general hospitals. This fundamental structure remains in place today, and there has been no indication that the state is preparing to change it by reducing its reliance on general hospitals. Many of us have come to the fairly obvious conclusion that before the Commission makes recommendations, there must be a rigorous, public process of review of all proposals that would result in the loss of behavioral health services. We believe that the Commission and the NYS Office of Mental Health should jointly cast a plan that takes into account possible closures of general hospitals and nursing homes and assures that adequate alternatives will be in place before general hospitals providing vital behavioral health services are closed or people with mental disorders are discharged from nursing homes. The plan should be based on specific answers to specific questions about specific facilities including:
Just to be clear, many of us believe that it may be possible for NYS to meet its people’s behavioral health care needs with fewer hospitals and nursing homes. But responsible closures require rigorous planning and the development of adequate alternatives before closures take place. Over the past quarter century NYS has made considerable progress towards building a decent community-based mental health system. General hospitals have been an essential element of that system. It is frightening to think that so much of the progress of the past 25 years could be undone if this Commission does not devote appropriate attention to behavioral health needs. That is why we hope to be able to work collaboratively with the Commission and with OMH to do the kind of rigorous planning that is needed when making major changes. (Michael B. Friedman is Director of the Center for Policy and Advocacy of the Mental Health Associations of The Mental Health Associations of NYC and of Westchester. Mr. Friedman can be reached by e-mail at center@mhaofnyc.org. The Center’s website is http://www.mhawestchester.org/advocates/metcenter.asp.) Return to the top of the page.
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