The Bazelon Center for Mental Health Law

Testimony by
Robert Bernstein, Ph.D.
Executive Director
Judge David L. Bazelon Center for Mental Health Law
Before
The Center for Mental Health Services
Acute Care Workgroup

October 5, 2004

Bio: Robert Bernstein, Ph.D. Get It Together: How to Integrate Physical and Mental Health Care for People with Serious Mental Disorders (Bazelon Center, 2004) A New Vision for Public Mental Health (Bazelon Center, 2002) The President's New Freedom Commission on Mental Health

As the nation’s public mental health systems have shifted the delivery of services from institutions to the community, the need for acute care has received increasing attention. Crisis centers and short-term psychiatric units in general hospitals are key elements of the current structure of acute care within mental health systems. And many state psychiatric institutions have sought to redefine themselves as acute-care settings. All share the goal of quickly resolving mental health crises, largely though adjusting psychiatric medications and quickly referring their patients back to community-based mental health programs.

My definition of acute care for people with mental illnesses —particularly in light of the transformation called for by the President’s New Freedom Commission on Mental Health— is less rooted in the bricks and mortar of hospital buildings. It is also less inclined to distinguish acute care from the ongoing services that will support individuals in their recovery process.

A system’s acute-care capacities should certainly include hospital-based services for people with immediate needs for 24-hour medical care. But where the conventional definition has acute care in a static location to which the individual is taken, I believe that, as we contemplate the transformation of public mental health we need to reassert a sometimes forgotten dictum from the community mental health movement: move services not people.

In my view, core acute care services should be mobile, supplementing, not supplanting the providers with whom the individual is familiar. And they should be readily available without requiring that an individual reach the point of being regarded as dangerous to self or others. When an individual’s needs are such that hospital care is required, the community providers should play an active role in providing services to the individual while hospitalized—a role significantly more meaningful than simply consulting around discharge planning.

Under any definition, however, the current acute-care system is gravely deficient. Almost everywhere, the system institutionalizes the revolving door, cyclically trading off clinical responsibility between the community clinic and the hospital. Both the acute-care and community systems operate under the implicit assumption that people with serious mental illnesses are destined to live unstable lives, marked by recurrent crises and repeated hospitalizations. People who work in hospitals commonly assume that the people they discharge will be back, over and over again —if not to their hospital, to another, or to a criminal justice setting. The posture of the current acute-care system is to rapidly stabilize the people who come to their door, then passively await their return. My experience is that acute-care providers have little optimism that the circumstances of consumers’ lives in the community will change, but a clear sense that the provider’s role ends once an individual walks out the door.

This scenario is too reminiscent of assumptions once common on psychiatric wards, where staff regarded behavioral emergencies as routine events, requiring that on a daily basis people were placed in restraints and seclusion rooms. Recent reforms have greatly reduced the use of restraint and seclusion and in the process have helped to redefine a behavioral crisis as a failure in proactive treatment. Even in the most underfunded state hospitals, arguably serving the most challenging populations, these reforms have prompted staff and consumers to review potential crises and responses at the point of admission, to institute early non-coercive interventions when individuals appear to be heading toward crises, and to examine factors in the individual, in staff approaches and in the environment that precipitate crises. Hospitals’ quality-improvement efforts now routinely include detailed data collection about behavioral crises and the effectiveness of their innovations toward virtually eliminating the use of seclusion and restraint. At the core of these changes are recognition that behavioral emergencies and reliance on seclusion and restraint represent system failures and a conviction that new approaches can produce better outcomes.

This essential change has yet to take hold across the public mental health system, however. For too many consumers and their families, psychiatric emergencies that culminate in transfer to an acute-care setting remain an immutable and routine occurrence—a harmful disruption of people’s lives and the continuity of their care. In part, this reality is sustained by the artificial programmatic schism between acute care and ongoing mental health services that dissipates accountability and leaves no time for either component to understand and correct the root causes of mental health crises. In my work I have had the opportunity to review many hundreds of hospital and community case records, particularly with regard to admissions and discharge processing. Overwhelmingly, analyses of why individuals come to experience psychiatric crises are limited to succinct statements to the effect that medications were not being taken as prescribed. And there is often shockingly little information about how, to what extent or even whether community services were being offered.

Of course, the community system is complicit in this scheme. In carrying out its role of pre-admission screening, it carefully documents on petitions for civil commitment that individuals have serious mental illnesses and are dangerous to themselves or others. And, because involuntary hospitalization is supposed to be a last resort, it dutifully checks off a box to affirm that less-restrictive alternatives are not viable. What they are or why they are not viable or whether they could have been viable if available are questions not generally asked or answered.

Mirroring what we have learned about reforms in seclusion/restraint use, the public mental health system needs to adopt the bold ambition that a responsive and flexible community system can eliminate —or at least virtually eliminate— the need for acute hospital care. And though this goal appears pie-in-the-sky, the system needs to operate as if it is attainable. One critical step relates to the gathering and use of information to drive changes on both individual and system levels. After every acute-care episode, careful analysis should be undertaken by the service team together with the consumer to identify how future crises can be averted and what to do if one occurs. Individuals should be encouraged to develop and maintain crisis plans that identify early indicators of problems and steps to be taken toward resolution.

In addition to refining individuals’ services, critical information from root cause analyses of acute-care episodes should be aggregated as a part of a visible systemwide quality-improvement effort to establish system reforms toward the elimination of psychiatric emergencies. These reforms may be as wide-ranging as enhancing supportive-housing options, strengthening peer-support systems and outreach, ensuring consumer choice in providers, treatment modalities and medications or creating opportunities for employment. In my mind, the extent to which these factors seem far afield from a discussion on improving acute care is a reflection of how disjointed mental health services have become, thus validating the findings of the President’s commission.

I am aware of considerable discussion about a shortage of acute-care psychiatric hospital beds, supported by statistics that show a rise in demand for hospital beds in various sectors. Background materials reviewed by this workgroup include at least a passing reference to the relationship between the demand for hospital beds and the capacity of the community system to provide alternative interventions. I think that it is important to recognize that the parameters of acute psychiatric hospital care are largely defined by default; hospitals attend to the people community systems cannot or do not adequately serve. If there is, indeed, a shortage of psychiatric hospital beds, there is an even greater shortage of alternative community services that might greatly reduce the demand for beds and, more important, reduce the disruptions in living that have come to be associated with serious mental illness.

Although I see it as an important operational goal, it would nevertheless be naive to predict an end to the need for acute psychiatric hospital care in the foreseeable future. Beyond the recommendation of launching a serious effort to gather and use information to spur improvements in preventive services, there are other important considerations in improving acute-care services. First of all, I believe acute care must be holistic care. Given the historic separation of physical from mental healthcare delivery systems and the potency of a diagnosis of “serious mental illness,” it is not surprising that the physical health of people so labeled is often given secondary consideration. In fact, people with serious mental illnesses are at particular risk for coexisting physical ailments. Furthermore, in light of their mental disabilities, they may be ill prepared to clearly articulate physical complaints during a crisis, particularly to disbelieving providers who are prone to label complaints as manifestations of psychosis. In my view, a comprehensive assessment of an individual in crisis is most likely to occur in a facility that offers a full range of healthcare services, namely, in an acute-care unit that is affiliated with a general hospital. A recent report by the Bazelon Center, Get It Together, looks at the integration of physical and mental health in ambulatory care settings. It suggests that co-located or embedded services may effectively break down traditional barriers between physical and mental healthcare and improve service outcomes. In this regard, the much-debated IMD rule may provide an important unintended benefit to Medicaid-eligible people with acute-care needs in that it encourages services in integrated healthcare facilities.

Finally, any move toward a more meaningful acute care system for people with serious mental illnesses must include means to preserve the dignity and respect the choices of individuals when all else fails and they require assistance during periods of temporary impairment. Advance mental health directives, while not trumping emergency medical decisions, encourage individuals to plan proactively and alert providers to personal preferences relating to interventions or substitute decision makers. They are an important element of any acute-care system.

In contemplating system transformation, we face a choice in values: How do we want the system to look? My view is that the increasing demand for hospital beds to deliver acute care is an artifact of the erosion of community resources. Since financing is an important driver of clinical practice, any effort to address shortages in hospital beds should be defined as temporary and be accompanied by meaningful expansions in the community services—including early intervention, mobile services and alternative diversion programs— that will reduce the demand for hospital care and support consumers’ progress toward recovery.