Statement by Chris Koyanagi, Policy Director
Bazelon Center for Mental Health Law
Regarding Acute Care Services Issues
We understand that the Commission is intending to address some
aspects of acute institutional care in its final report and beginning
to discuss these questions. Acute care in hospitals and other 24-hour
facilities is, of course, an important part of any continuum of
mental health services when all community-based options have been
exhausted. Without question, some people at some points in time
must have 24-hour acute care. Institutional care is only appropriate
when it both stabilizes a person's mental illness and includes attention
to long-term stability after discharge by offering services in a
respectful way that is sensitive to the individual's goals and preferences.
The use of advance directives and adoption of person-centered approaches
to treatment planning are important components of hospital services
that embrace the them of recovery that the Commission is promoting.
The Bazelon Center would like to emphasize several points regarding
the Commission's analysis of acute hospital and institutional care.
First, the hub of mental health systems today is in the community.
The role of institutional care in any community is determined in
large part by the capacity and effectiveness of the community system.
Addressing issues of perceived lack of capacity for acute institutional
care is best achieved by ensuring a strong community systems that
prevent de-compensation and relapse and provide consumers with appropriate,
effective services of their choice. Nowhere in this country does
such a community system exist.
To pay for failures in the community by paying for intensive 24-hour
services is inefficient. Weakening the community response by draining
resources into 24-hour care is cruel for those who need intensive
supports on a daily basis to prevent repeated hospitalizations.
Secondly, there are effective community-based 24-hour services that
can redefine the role of traditional institutional-based acute care.
For adults, an expansion of crisis-residential beds would go a long
way to avoiding hospitalizations. For children, therapeutic foster
care is far preferable – and when long-term outcomes are considered
far more effective – than residential treatment centers. We
need to fund what works best, and not needlessly rely on institutional
services.
Thirdly, all payers seem far more willing to fund services for
those in an acute stage of crisis than to fund the essential community
support services that could have prevented the crisis in the first
place. The Commission does not need to emphasize resource issues
for acute care – it is, despite the clear shortcomings –
the best funded part of the system. When policymakers make cuts
in budgets, the first cuts are generally preventive or low-cost
outpatient services for those with less serious disorders. Such
cost reductions are short-sighted and often result in increased
demand for expensive, high-end services. Moreover, when institutional
care is paid for, it is almost always paid for at cost or cost-plus.
Community programs may lose money on every person served; institutions
rarely do.
It is important, too, to take an historical view of these services.
In the past, reform efforts focused on improving hospitals, then
they focused on emptying them and today we focus, as the President
makes abundantly clear in the Executive Order, on helping people
attain community membership. The Commission might find helpful the
chart attached to my statement and prepared by Robert Bernstein,
Bazelon Center Executive Director, which lays out how some important
questions are answered very differently today than in the past.
For example, look at the question of how vulnerabilities are handled.
Let us not return to thinking about how to provide safe havens instead
of focusing on the supports needed to help people address their
needs in the community setting.
The Commission is seeking information on what data might be useful
regarding acute care. We think it would be helpful for the Commission
to urge that policy makers review:
- The number and characteristics of individuals discharged from
state and private mental hospitals who return to the institution
or a similar setting within short periods of time;
- The number and characteristics of individuals with repeated
hospitalizations during any one year;
- The length of time from discharge to a follow-up outpatient
service;
- The adequacy of discharge-planning;
- The number of individuals who have been in contact with the
public mental health system who are later arrested for crimes
that relate to their untreated mental illness; and
- State and private mental hospitals that have pre-release agreements
with Social Security so as to ensure re-instatement (or initial
application) for disability benefits.
However, while these types of data would be most helpful, it is
very difficult to obtain most of this information. We not only need
better data, but we need to address the fundamental problems that
get in the way of capturing this information. For example, data
may be available on re-admissions to the same facility, but it is
not generally available when the individual is admitted to two different
hospitals or arrested and incarcerated in a jail. Specific efforts
would need to be made to gather more useful information. One mechanism
would be to work through community providers – particularly
case managers – who hold, or should hold, the necessary information.
They ought to know where their clients are and when.
In addition to specific data, any discussion of this issue by the
Commission needs to include a qualitative analysis of what failure
in the community caused this acute episode. Otherwise, we will not
understand what is really happening in people's lives and why the
demand for various services, including acute institutional care,
is what it is. In other words, we cannot look in isolation only
at acute care.
Another qualitative issue is the standards within acute care facilities.
We should not overlook issues such as reducing or eliminating seclusion
and restraint, particularly in private facilities which have a worse
track record than the public hospitals. We should cry out against
policies that deny children access to their own parents and other
family members while they are in a treatment facility. It should
never be a "reward" that a youngster can see her family.
I hope these comments are helpful. Thank you for the opportunity
to present them.
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The Bazelon Center for Mental Health Law is the nation’s
leading legal advocate for the rights of people with mental disabilities.
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